Provider Demographics
NPI:1568921427
Name:HENRY, NICHOLAI ANTHONY (MD)
Entity type:Individual
Prefix:
First Name:NICHOLAI
Middle Name:ANTHONY
Last Name:HENRY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1412 MILSTEAD AVE NE STE 100
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30012-3877
Mailing Address - Country:US
Mailing Address - Phone:770-483-9330
Mailing Address - Fax:770-483-3731
Practice Address - Street 1:1412 MILSTEAD AVE NE STE 100
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30012-3877
Practice Address - Country:US
Practice Address - Phone:770-483-9330
Practice Address - Fax:770-483-3731
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1030072086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY64172Medicaid