Provider Demographics
NPI:1588634414
Name:HENRICH, DOUGLAS EDWIN (MD)
Entity Type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:EDWIN
Last Name:HENRICH
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 1:1225 S GEAR AVE
Mailing Address - Street 2:STE 255
Mailing Address - City:WEST BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52655-1687
Mailing Address - Country:US
Mailing Address - Phone:319-752-2725
Mailing Address - Fax:319-753-1084
Practice Address - Street 1:1225 S GEAR AVE
Practice Address - Street 2:STE 255
Practice Address - City:WEST BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1687
Practice Address - Country:US
Practice Address - Phone:319-752-2725
Practice Address - Fax:319-753-1084
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA31549207K00000X, 207KA0200X, 207KI0005X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0151092Medicaid
IA58619OtherWELLMARK #
IA58619OtherWELLMARK #
IA0151092Medicaid
IA58619OtherWELLMARK #