Provider Demographics
NPI:1194781294
Name:HENRY, GERRIT V (D,IO)
Entity type:Individual
Prefix:DR
First Name:GERRIT
Middle Name:V
Last Name:HENRY
Suffix:
Gender:M
Credentials:D,IO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:8712 N 68TH ST
Mailing Address - Street 2:
Mailing Address - City:PARADISE VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:85253-2703
Mailing Address - Country:US
Mailing Address - Phone:480-329-6966
Mailing Address - Fax:408-904-7730
Practice Address - Street 1:9460 N NAME UNO STE 210
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-3532
Practice Address - Country:US
Practice Address - Phone:408-847-0888
Practice Address - Fax:408-847-1257
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA12356207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ66158Medicare ID - Type Unspecified