Provider Demographics
NPI:1245232917
Name:HENRY, CLARENCE B (MD)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:B
Last Name:HENRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:949 COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:NY
Mailing Address - Zip Code:12534-2624
Mailing Address - Country:US
Mailing Address - Phone:518-828-7188
Mailing Address - Fax:518-828-5049
Practice Address - Street 1:949 COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12534-2624
Practice Address - Country:US
Practice Address - Phone:518-828-7188
Practice Address - Fax:518-828-5049
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY128189207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00663025Medicaid
NY00663025Medicaid
NYB88692Medicare UPIN