Provider Demographics
NPI:1902056252
Name:HENRICKSON, RONALD RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:RUSSELL
Last Name:HENRICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32318 BISSON LN
Mailing Address - Street 2:
Mailing Address - City:POLSON
Mailing Address - State:MT
Mailing Address - Zip Code:59860-7354
Mailing Address - Country:US
Mailing Address - Phone:406-883-5723
Mailing Address - Fax:
Practice Address - Street 1:32318 BISSON LN
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-7354
Practice Address - Country:US
Practice Address - Phone:406-883-5723
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-23
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4778207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery