Provider Demographics
NPI:1750389029
Name:HENRY, CLARKE LATTA JR (MD)
Entity type:Individual
Prefix:
First Name:CLARKE
Middle Name:LATTA
Last Name:HENRY
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8901 W 74TH STREET
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SHAWNEE MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66204-2201
Mailing Address - Country:US
Mailing Address - Phone:913-341-0120
Mailing Address - Fax:913-341-6071
Practice Address - Street 1:8901 W 74TH ST
Practice Address - Street 2:SUITE 1
Practice Address - City:SHAWNEE MISSION
Practice Address - State:KS
Practice Address - Zip Code:66204-2204
Practice Address - Country:US
Practice Address - Phone:913-341-0120
Practice Address - Fax:913-344-6071
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7F67208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202277919Medicaid
MO202277919Medicaid
F46255Medicare UPIN