Provider Demographics
NPI:1699044347
Name:HENRY, MARIETTA MAE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIETTA
Middle Name:MAE
Last Name:HENRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8211 SCICOR DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-2942
Mailing Address - Country:US
Mailing Address - Phone:317-273-7934
Mailing Address - Fax:317-273-7990
Practice Address - Street 1:8211 SCICOR DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46214-2942
Practice Address - Country:US
Practice Address - Phone:317-273-7934
Practice Address - Fax:317-273-7990
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-27
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01021501A1744R1102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744R1102XOther Service ProvidersSpecialistResearch Study