Provider Demographics
NPI:1497010730
Name:JOHNNY LEE HENRY, M.D.,P.A.
Entity Type:Organization
Organization Name:JOHNNY LEE HENRY, M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:CASELLA
Authorized Official - Suffix:
Authorized Official - Credentials:PHYSICIAN ASSISTANT
Authorized Official - Phone:214-631-2653
Mailing Address - Street 1:8200 BROOKRIVER DR
Mailing Address - Street 2:SUITE N-512
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75247-4069
Mailing Address - Country:US
Mailing Address - Phone:214-631-2653
Mailing Address - Fax:214-637-9063
Practice Address - Street 1:8200 BROOKRIVER DR
Practice Address - Street 2:SUITE N-512
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75247-4069
Practice Address - Country:US
Practice Address - Phone:214-631-2653
Practice Address - Fax:214-637-9063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-12
Last Update Date:2012-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE0974207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX032327101Medicaid
TX032327101Medicaid