Basic Information
| Provider Information | |||||||||
| NPI: | 1740205822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 MEDICAL CIR | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226013322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406671828 | ||||||||
| FaxNumber: | 5407223658 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 MEDICAL CIR | ||||||||
| Address2: | |||||||||
| City: | WINCHESTER | ||||||||
| State: | VA | ||||||||
| PostalCode: | 226013322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5406671828 | ||||||||
| FaxNumber: | 5407223658 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2006 | ||||||||
| LastUpdateDate: | 03/11/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084V0102X | 236665 | NY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Vascular Neurology | 2084N0400X | 0101251919 | VA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 02685358 | 05 | NY | MEDICAID | MDJ060 | 01 | PREFERRED CARE | OTHER | P010236665 | 01 | BLUE CHOICE | OTHER | P020236665 | 01 | BLUE SHIELD | OTHER |