Provider Demographics
NPI:1639133580
Name:HENRY, HAYDEN D (MD)
Entity Type:Individual
Prefix:
First Name:HAYDEN
Middle Name:D
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:PO BOX 1571
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-1571
Mailing Address - Country:US
Mailing Address - Phone:580-226-8310
Mailing Address - Fax:580-223-3911
Practice Address - Street 1:915 10TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-4025
Practice Address - Country:US
Practice Address - Phone:580-226-8310
Practice Address - Fax:580-223-3911
Is Sole Proprietor?:No
Enumeration Date:2006-04-15
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17670208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100067550AMedicaid
OK731521343OtherTAX I.D. NUMBER
OKF37537Medicare UPIN
OK731521343OtherTAX I.D. NUMBER