Provider Demographics
NPI:1710935234
Name:HENRY, GRANT H (MD)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:H
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 1:202 JAMES COLEMAN DR
Mailing Address - Street 2:STE A
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77904-3109
Mailing Address - Country:US
Mailing Address - Phone:361-573-4000
Mailing Address - Fax:361-579-4949
Practice Address - Street 1:202 JAMES COLEMAN DR
Practice Address - Street 2:STE A
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77904-3109
Practice Address - Country:US
Practice Address - Phone:361-573-4000
Practice Address - Fax:361-579-4949
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0430207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173812202Medicaid
TX8DS816OtherBLUE CROSS
TX7607690OtherAETNA
TX173812201Medicaid
TX8S4334OtherBLUE CROSS
TX8J2013OtherBCBS
TX8D8810Medicare PIN
I29352Medicare UPIN
TX173812202Medicaid