Provider Demographics
NPI:1043247380
Name:HENRY, NICKSON (OD)
Entity type:Individual
Prefix:DR
First Name:NICKSON
Middle Name:
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 1:3564 HIGHWAY 138 SE
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4170
Mailing Address - Country:US
Mailing Address - Phone:770-474-5617
Mailing Address - Fax:770-474-6576
Practice Address - Street 1:3564 HIGHWAY 138 SE
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-4170
Practice Address - Country:US
Practice Address - Phone:770-474-5617
Practice Address - Fax:770-474-6576
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2014-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2263152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA238123293BMedicaid
GAV12058Medicare UPIN
GA238123293BMedicaid