Provider Demographics
NPI:1831284272
Name:HENRY, GLENDON C (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENDON
Middle Name:C
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 1:506 LENOX AVENUE
Mailing Address - Street 2:WP-522
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-5501
Mailing Address - Country:US
Mailing Address - Phone:212-939-2740
Mailing Address - Fax:212-939-2759
Practice Address - Street 1:506 LENOX AVENUE
Practice Address - Street 2:WP-522
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-5501
Practice Address - Country:US
Practice Address - Phone:212-939-2740
Practice Address - Fax:212-939-2759
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY177608207PT0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF30397Medicare UPIN
NY66K522Medicare ID - Type Unspecified