Provider Demographics
NPI:1558333179
Name:HENSTROM, DOUGLAS K (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:K
Last Name:HENSTROM
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 1:2255 N 1700 W
Mailing Address - Street 2:STE 200
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-1187
Mailing Address - Country:US
Mailing Address - Phone:801-776-2220
Mailing Address - Fax:801-820-2772
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1007
Practice Address - Country:US
Practice Address - Phone:319-356-3600
Practice Address - Fax:319-356-4547
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47669207Y00000X
IA39672207Y00000X, 207YS0123X, 207YX0905X
UT10222796-1205207YX0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN767689100Medicaid
MN040000782Medicare ID - Type Unspecified
I40187Medicare UPIN