Provider Demographics
NPI:1235168592
Name:HENRIE, ARLAN MICHAEL (DO)
Entity Type:Individual
Prefix:
First Name:ARLAN
Middle Name:MICHAEL
Last Name:HENRIE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:590 S WAKARA WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1200
Mailing Address - Country:US
Mailing Address - Phone:801-587-5458
Mailing Address - Fax:
Practice Address - Street 1:30 N 1900 E
Practice Address - Street 2:GRADUATE MEDICAL EDUCATION OFFICE RM 1C412
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0002
Practice Address - Country:US
Practice Address - Phone:801-585-2589
Practice Address - Fax:801-585-2507
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT371548-1204208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTP00905611OtherRAILROAD MEDICARE