Provider Demographics
NPI:1851376099
Name:HENRY, MELVIN L (MD)
Entity Type:Individual
Prefix:
First Name:MELVIN
Middle Name:L
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 1:1901 S CEDAR ST
Mailing Address - Street 2:SUITE 301 CARDIAC STUDY CENTER, INC. P.S.
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2308
Mailing Address - Country:US
Mailing Address - Phone:253-572-7320
Mailing Address - Fax:253-627-3191
Practice Address - Street 1:1901 S CEDAR ST
Practice Address - Street 2:SUITE 301 CARDIAC STUDY CENTER, INC. P.S.
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2308
Practice Address - Country:US
Practice Address - Phone:253-572-7320
Practice Address - Fax:253-627-3191
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00010897207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1364207Medicaid
A08439Medicare UPIN
WA1364207Medicaid