Provider Demographics
NPI:1427029321
Name:HENRY, THOMAS PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:PAUL
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 1:10373 NE HANCOCK ST
Mailing Address - Street 2:#112
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3873
Mailing Address - Country:US
Mailing Address - Phone:503-254-2808
Mailing Address - Fax:503-254-2867
Practice Address - Street 1:10373 NE HANCOCK ST
Practice Address - Street 2:#112
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3873
Practice Address - Country:US
Practice Address - Phone:503-254-2808
Practice Address - Fax:503-254-2867
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11446207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR231241Medicaid
C91799Medicare UPIN
0000BJBNKMedicare ID - Type Unspecified