Provider Demographics
NPI:1306970900
Name:HENRY, ROBERT EMMETT III (MD, MS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:EMMETT
Last Name:HENRY
Suffix:III
Gender:M
Credentials:MD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100-7 RANCH ROAD
Mailing Address - Street 2:348
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-6017
Mailing Address - Country:US
Mailing Address - Phone:805-497-4414
Mailing Address - Fax:
Practice Address - Street 1:558 SAINT CHARLES DR
Practice Address - Street 2:SUITE 200
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-3903
Practice Address - Country:US
Practice Address - Phone:805-379-2322
Practice Address - Fax:805-379-2373
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAGO74794204C00000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG74794EOtherMEDICARE PTAN
CACC801ZOtherPTAN
CACC801YOtherADDITIONAL PTAN
CAW9293Medicare PIN
CACC801YOtherADDITIONAL PTAN
CAW9293AMedicare PIN