Provider Demographics
NPI:1184829525
Name:HENRY, MIYOSHI LIZETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:MIYOSHI
Middle Name:LIZETTE
Last Name:HENRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1150 ROBERT BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2005
Mailing Address - Country:US
Mailing Address - Phone:985-646-1122
Mailing Address - Fax:888-865-7591
Practice Address - Street 1:1150 ROBERT BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458
Practice Address - Country:US
Practice Address - Phone:985-646-1122
Practice Address - Fax:888-865-7591
Is Sole Proprietor?:No
Enumeration Date:2007-06-17
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200523207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1090271Medicaid
LA1090271Medicaid
LA5BC69Medicare PIN