Provider Demographics
NPI:1336269877
Name:HENRY, FREDERICK CONRAD (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:CONRAD
Last Name:HENRY
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 1:2200 N 61ST AVE
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32506-3238
Mailing Address - Country:US
Mailing Address - Phone:808-265-0067
Mailing Address - Fax:
Practice Address - Street 1:8383 N DAVIS HWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6039
Practice Address - Country:US
Practice Address - Phone:850-494-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 84268207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIU982364Medicare UPIN