Provider Demographics
NPI:1861404824
Name:HENRY, BRUCE BEAUMONT (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:BEAUMONT
Last Name:HENRY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 FOREST LN
Mailing Address - Street 2:A222
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230
Mailing Address - Country:US
Mailing Address - Phone:972-566-7970
Mailing Address - Fax:972-566-3821
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:A222
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2505
Practice Address - Country:US
Practice Address - Phone:972-566-7970
Practice Address - Fax:972-566-3821
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG7472207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84160XOtherBCBS
TX00473KMedicare ID - Type UnspecifiedMEDICARE
TXC16827Medicare UPIN