Provider Demographics
NPI:1811925183
Name:HENRY, STEPHEN DOUGLAS (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DOUGLAS
Last Name:HENRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:2319 E WASHINGTON BLVD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-1945
Mailing Address - Country:US
Mailing Address - Phone:626-797-8800
Mailing Address - Fax:626-797-8079
Practice Address - Street 1:2319 E WASHINGTON BLVD
Practice Address - Street 2:SUITE 2
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-1945
Practice Address - Country:US
Practice Address - Phone:626-797-8800
Practice Address - Fax:626-797-8575
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2011-05-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAC37981207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC37981OtherSTATE LICENSE
953652123OtherFEDERAL TAX ID
A36807Medicare UPIN