Basic Information
| Provider Information | |||||||||
| NPI: | 1417970948 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENRICKS | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | GLENN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3434 HANCOCK BRIDGE PKWY STE 301 | ||||||||
| Address2: | |||||||||
| City: | NORTH FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339037099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778563774 | ||||||||
| FaxNumber: | 2395992612 | ||||||||
| Practice Location | |||||||||
| Address1: | 2450 TAMIAMI TRL | ||||||||
| Address2: | |||||||||
| City: | PORT CHARLOTTE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9416242704 | ||||||||
| FaxNumber: | 9416276066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 03/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME0041258 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 36367V | 01 | FL | UNSPECIFIED | OTHER |