Provider Demographics
NPI:1518901222
Name:HENRY, SHAWN MARK (DO)
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:MARK
Last Name:HENRY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 S WHITE CHAPEL BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-7316
Mailing Address - Country:US
Mailing Address - Phone:817-429-4545
Mailing Address - Fax:817-429-4547
Practice Address - Street 1:3600 W 7TH ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2534
Practice Address - Country:US
Practice Address - Phone:817-429-4545
Practice Address - Fax:817-429-4547
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2316207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1454696-02Medicaid
TX1454696-01Medicaid
TXH38852Medicare UPIN
TX8248K8Medicare PIN
TX1454696-01Medicaid