Provider Demographics
NPI:1720173057
Name:HENRY, MICHAEL EVAN (DPM)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EVAN
Last Name:HENRY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 NORTH BANCROFT PARKWAY
Mailing Address - Street 2:SUITE 12
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-2668
Mailing Address - Country:US
Mailing Address - Phone:302-658-1129
Mailing Address - Fax:302-658-7646
Practice Address - Street 1:1010 NORTH BANCROFT PARKWAY
Practice Address - Street 2:SUITE 12
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-2668
Practice Address - Country:US
Practice Address - Phone:302-658-1129
Practice Address - Fax:302-658-7646
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEE1000170213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000036543Medicaid
DEV05259Medicare UPIN
DE0857930002Medicare NSC
DE1000036543Medicaid