Provider Demographics
NPI:1417970948
Name:HENRICKS, DOUGLAS GLENN (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:GLENN
Last Name:HENRICKS
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 1:3434 HANCOCK BRIDGE PKWY STE 301
Mailing Address - Street 2:
Mailing Address - City:NORTH FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33903-7099
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:239-599-2612
Practice Address - Street 1:2450 TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:PORT CHARLOTTE
Practice Address - State:FL
Practice Address - Zip Code:33952
Practice Address - Country:US
Practice Address - Phone:941-624-2704
Practice Address - Fax:941-627-6066
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0041258207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL36367VOtherUNSPECIFIED
FLE60838Medicare UPIN