Provider Demographics
NPI:1528036845
Name:HENRY, LEE FREDERIC (DO)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:FREDERIC
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 1:404 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:PELLA
Mailing Address - State:IA
Mailing Address - Zip Code:50219-1291
Mailing Address - Country:US
Mailing Address - Phone:641-628-3150
Mailing Address - Fax:641-628-8901
Practice Address - Street 1:404 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:PELLA
Practice Address - State:IA
Practice Address - Zip Code:50219-1291
Practice Address - Country:US
Practice Address - Phone:641-628-3150
Practice Address - Fax:641-628-8901
Is Sole Proprietor?:No
Enumeration Date:2006-03-11
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA024762085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0321455Medicaid
IA300036501OtherRAILROAD MEDICARE
IA300036501OtherRAILROAD MEDICARE
IA32145Medicare ID - Type UnspecifiedMEDICARE NUMBER
IA32145Medicare PIN