Provider Demographics
NPI:1144363771
Name:HENRY, WILLIAM O (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:O
Last Name:HENRY
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:PO BOX 2819
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39505-2819
Mailing Address - Country:US
Mailing Address - Phone:228-314-7226
Mailing Address - Fax:228-314-7227
Practice Address - Street 1:14245 DEDEAUX RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3369
Practice Address - Country:US
Practice Address - Phone:228-314-7226
Practice Address - Fax:228-314-7227
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08744174400000X
TXF7484174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1906808Medicaid
MT3504397Medicaid
MS10410Medicaid
TN1995131Medicaid
TXX9X008188Medicaid
TXX9X008188Medicaid
LA1906808Medicaid