Provider Demographics
NPI:1447324678
Name:HENRY, MICHAEL JEROME
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JEROME
Last Name:HENRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:JEROME
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:648 NORTHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95833-2442
Mailing Address - Country:US
Mailing Address - Phone:916-927-3422
Mailing Address - Fax:
Practice Address - Street 1:648 NORTHFIELD DR
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95833-2442
Practice Address - Country:US
Practice Address - Phone:916-927-3422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40497174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD76041Medicare UPIN