Provider Demographics
NPI:1881845170
Name:JOHN C. HENRY, M.D., P.A.
Entity Type:Organization
Organization Name:JOHN C. HENRY, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GLENDA
Authorized Official - Middle Name:F
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-624-2330
Mailing Address - Street 1:207 N UNION AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-3068
Mailing Address - Country:US
Mailing Address - Phone:575-624-2330
Mailing Address - Fax:575-622-9133
Practice Address - Street 1:207 N UNION AVE
Practice Address - Street 2:SUITE C
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-3068
Practice Address - Country:US
Practice Address - Phone:575-624-2330
Practice Address - Fax:575-622-9133
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-05
Last Update Date:2008-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM83-218207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM25239Medicaid
NMD43162Medicare UPIN
NM25239Medicaid