Basic Information
| Provider Information | |||||||||
| NPI: | 1558333179 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENSTROM | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2255 N 1700 W | ||||||||
| Address2: | STE 200 | ||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840411187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017762220 | ||||||||
| FaxNumber: | 8018202772 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HAWKINS DR | ||||||||
| Address2: | |||||||||
| City: | IOWA CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 522421007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3193563600 | ||||||||
| FaxNumber: | 3193564547 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 04/11/2017 | ||||||||
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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 | 207Y00000X | 47669 | MN | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 39672 | IA | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207YS0123X | 39672 | IA | N | Allopathic & Osteopathic Physicians | Otolaryngology | Facial Plastic Surgery | 207YX0905X | 39672 | IA | N | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery | 207YX0007X | 10222796-1205 | UT | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck |
ID Information
| ID | Type | State | Issuer | Description | 767689100 | 05 | MN | MEDICAID |