Provider Demographics
NPI:1447366901
Name:HENICK, DAVID H (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:H
Last Name:HENICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 BRIDGE PLZ N
Mailing Address - Street 2:
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-5059
Mailing Address - Country:US
Mailing Address - Phone:201-592-8200
Mailing Address - Fax:201-592-7786
Practice Address - Street 1:301 BRIDGE PLZ N
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-5059
Practice Address - Country:US
Practice Address - Phone:201-592-8200
Practice Address - Fax:201-592-7786
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06039500174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ134533Medicare ID - Type Unspecified
NJF67180Medicare UPIN