Provider Demographics
NPI:1740240308
Name:HENRY, ROBERT A JR (DO)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:HENRY
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2817 NEW PINERY ROAD
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:WI
Mailing Address - Zip Code:53901-9257
Mailing Address - Country:US
Mailing Address - Phone:608-742-4131
Mailing Address - Fax:
Practice Address - Street 1:2817 NEW PINERY ROAD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-9257
Practice Address - Country:US
Practice Address - Phone:608-742-4131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH1102207Q00000X
WI65243-21207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX807629OtherBLUE SHIELD
TX1010845-02Medicaid
TX080161793OtherRR/MEDICARE
TX1010845-01OtherCSHCN
TX080161793OtherRR/MEDICARE
TXA67063Medicare UPIN