Provider Demographics
NPI:1982664116
Name:HENRY, SCOTT J (OD)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:J
Last Name:HENRY
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 1:132 WILLOWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9272
Mailing Address - Country:US
Mailing Address - Phone:304-546-1223
Mailing Address - Fax:
Practice Address - Street 1:500 WINCHESTER AVE UNIT 810
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7362
Practice Address - Country:US
Practice Address - Phone:606-324-3672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10241269-9934152W00000X
WV0936-IOD152W00000X
OHOPT.006517152W00000X
KY2091DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0149908000Medicaid
WV0149908000Medicaid
WVU59019Medicare UPIN