Provider Demographics
NPI:1750377958
Name:HENRY, DOUGLAS J (OD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
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 1:168 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5626
Mailing Address - Country:US
Mailing Address - Phone:207-784-3564
Mailing Address - Fax:207-782-2541
Practice Address - Street 1:168 EAST AVE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5626
Practice Address - Country:US
Practice Address - Phone:207-784-3564
Practice Address - Fax:207-782-2541
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT833152W00000X, 152WC0802X, 152WX0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WX0102XEye and Vision Services ProvidersOptometristOccupational Vision
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME0324520001OtherDME
ME025957OtherANTHEM-BC/BS
ME322020099Medicaid
MEU76915Medicare UPIN
ME322020099Medicaid