Provider Demographics
NPI:1447257480
Name:HENRY, LYNN R (OD)
Entity type:Individual
Prefix:DR
First Name:LYNN
Middle Name:R
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 1:23 CENTRAL PLZ
Mailing Address - Street 2:
Mailing Address - City:ILION
Mailing Address - State:NY
Mailing Address - Zip Code:13357-1701
Mailing Address - Country:US
Mailing Address - Phone:315-894-3325
Mailing Address - Fax:315-894-6000
Practice Address - Street 1:23 CENTRAL PLZ
Practice Address - Street 2:
Practice Address - City:ILION
Practice Address - State:NY
Practice Address - Zip Code:13357-1701
Practice Address - Country:US
Practice Address - Phone:315-894-3325
Practice Address - Fax:315-894-6000
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV003458-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY32491BMedicare ID - Type Unspecified
NYT26382Medicare UPIN
SC0179070001Medicare NSC