Provider Demographics
NPI:1255330247
Name:DVORAK, HENRY M (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:M
Last Name:DVORAK
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 1:500 S MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-1752
Mailing Address - Country:US
Mailing Address - Phone:952-442-2191
Mailing Address - Fax:952-442-6535
Practice Address - Street 1:500 S MAPLE ST
Practice Address - Street 2:
Practice Address - City:WACONIA
Practice Address - State:MN
Practice Address - Zip Code:55387-1752
Practice Address - Country:US
Practice Address - Phone:952-442-2191
Practice Address - Fax:952-442-6535
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2008-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN38681207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN362227400Medicaid
MNG57504Medicare UPIN