Provider Demographics
NPI:1295842805
Name:HENRY, JULIE M (OD)
Entity Type:Individual
Prefix:DR
First Name:JULIE
Middle Name:M
Last Name:HENRY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:MARIE
Other - Last Name:RONK
Other - Suffix:
Other - Last Name Type:Doing Business As
Other - Credentials:
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:414-647-6326
Mailing Address - Fax:414-671-8860
Practice Address - Street 1:210 WISCONSIN AMERICAN DR
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935
Practice Address - Country:US
Practice Address - Phone:920-907-7000
Practice Address - Fax:920-907-7012
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2979-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38628000Medicaid
MH1172701OtherDEA NUMBER
WI38628000Medicaid