Provider Demographics
NPI:1326274929
Name:HENRY, JOSHUA MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:MICHAEL
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:PO BOX 699
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:TN
Mailing Address - Zip Code:37684-0699
Mailing Address - Country:US
Mailing Address - Phone:423-433-6039
Mailing Address - Fax:423-433-6060
Practice Address - Street 1:325 N. STATE OF FRANKLIN ROAD, GROUND FLOOR
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604
Practice Address - Country:US
Practice Address - Phone:423-439-7320
Practice Address - Fax:423-439-7343
Is Sole Proprietor?:No
Enumeration Date:2009-06-09
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31732208000000X
KY46043208000000X
TN54572208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100332640Medicaid
IN201281690Medicaid
VA1326274929Medicaid
TNQ023478Medicaid
SC317320Medicaid
SC317320Medicaid
TN103I378668Medicare PIN
KYK194540Medicare PIN