Basic Information
| Provider Information | |||||||||
| NPI: | 1104211333 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31 VILLAGE SQ | ||||||||
| Address2: | |||||||||
| City: | CHELMSFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018242712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9782569507 | ||||||||
| FaxNumber: | 9782566955 | ||||||||
| Practice Location | |||||||||
| Address1: | 31 VILLAGE SQ | ||||||||
| Address2: | |||||||||
| City: | CHELMSFORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018242712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9782569507 | ||||||||
| FaxNumber: | 9782566955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2015 | ||||||||
| LastUpdateDate: | 06/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 282116 | MA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Urology |
No ID Information.