Basic Information
| Provider Information | |||||||||
| NPI: | 1952348096 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENRIQUES | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 9TH ST STE 203 | ||||||||
| Address2: | |||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955216249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078268633 | ||||||||
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| Practice Location | |||||||||
| Address1: | 38883 HWY 299 | ||||||||
| Address2: | |||||||||
| City: | WILLOW CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306293111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 10/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD26122 | OR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | G75329 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 096511 | 05 | OR | MEDICAID | 22959 | 05 | OR | MEDICAID |