Provider Demographics
NPI:1821081738
Name:HENRIKSEN, PAUL A (OD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:A
Last Name:HENRIKSEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 686
Mailing Address - Street 2:
Mailing Address - City:PIPESTONE
Mailing Address - State:MN
Mailing Address - Zip Code:56164-0686
Mailing Address - Country:US
Mailing Address - Phone:507-825-5444
Mailing Address - Fax:507-825-5286
Practice Address - Street 1:212 W. MAIN ST.
Practice Address - Street 2:
Practice Address - City:PIPESTONE
Practice Address - State:MN
Practice Address - Zip Code:56164-1634
Practice Address - Country:US
Practice Address - Phone:507-825-5444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2020-01-22
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
MN1922152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN896523400Medicaid
MNT65615Medicare UPIN