Provider Demographics
NPI:1730117672
Name:LIN, HENRY (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:
Last Name:LIN
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 1:1501 SAN PEDRO DR SE
Mailing Address - Street 2:111
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87108-5153
Mailing Address - Country:US
Mailing Address - Phone:505-265-1711
Mailing Address - Fax:
Practice Address - Street 1:1501 SAN PEDRO DR SE
Practice Address - Street 2:111
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5153
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG52549207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G525490OtherBLUE SHIELD
CACE1617OtherGROUP RAILROAD MEDICARE
CAGR0016910OtherGROUP MEDICAID
CA1356390009OtherGROUP NPI
CAW11675OtherGROUP MEDICARE PIN
CA00A525490Medicaid
CAWG52549CMedicare PIN
CACE1617OtherGROUP RAILROAD MEDICARE