Provider Demographics
NPI:1609867019
Name:HENRY, ANTHONY C (DO)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:C
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 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:MEDPARTNERS, ATTN: MEGAN FORTNEY
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3515
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:2512 E DUPONT RD STE 210
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1609
Practice Address - Country:US
Practice Address - Phone:260-458-3723
Practice Address - Fax:260-458-3724
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001404A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000091891OtherBLUE CROSS BLUE SHIELD
INP00970619OtherRAILROAD MEDICARE
IN100329430Medicaid
F33205Medicare UPIN
INP00970619OtherRAILROAD MEDICARE
IN080121939OtherRAILROAD MEDICARE
000000091891OtherBLUE CROSS BLUE SHIELD
1389OtherPHYSICIANS HEALTH PLAN
IN925530GMedicare PIN
INM400048190Medicare PIN