Provider Demographics
NPI:1629044003
Name:HENRY, BRYAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:HENRY
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 1:1530 RAILROAD AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT HELENA
Mailing Address - State:CA
Mailing Address - Zip Code:94574-1106
Mailing Address - Country:US
Mailing Address - Phone:707-963-5006
Mailing Address - Fax:
Practice Address - Street 1:1530 RAILROAD AVE
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-1106
Practice Address - Country:US
Practice Address - Phone:707-963-5006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37110174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA28297Medicare UPIN