Provider Demographics
NPI:1730490707
Name:C ALLAN HENRY MD PC
Entity Type:Organization
Organization Name:C ALLAN HENRY MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CONRAD
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-480-0111
Mailing Address - Street 1:1881 E LITTLE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518-4222
Mailing Address - Country:US
Mailing Address - Phone:757-480-0111
Mailing Address - Fax:757-480-1626
Practice Address - Street 1:1881 E LITTLE CREEK RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23518-4222
Practice Address - Country:US
Practice Address - Phone:757-480-0111
Practice Address - Fax:757-480-1626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101033212207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA66399827Medicaid
VA180000672OtherRAILROAD MEDICARE
VA322145OtherANTHEM BLUE CROSS
VA322145OtherANTHEM BLUE CROSS
B08904Medicare PIN