Provider Demographics
NPI:1639168578
Name:HENRY, GLEN ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:ALLEN
Last Name:HENRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5300 N INDEPENDENCE AVE
Mailing Address - Street 2:SUITE 280
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-5556
Mailing Address - Country:US
Mailing Address - Phone:405-949-3308
Mailing Address - Fax:405-951-8685
Practice Address - Street 1:3300 NW EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4418
Practice Address - Country:US
Practice Address - Phone:405-949-3308
Practice Address - Fax:405-951-8685
Is Sole Proprietor?:No
Enumeration Date:2005-10-13
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK20224207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1003132110AMedicaid
OK1003132110AMedicaid
OK244525001Medicare ID - Type Unspecified