Healthcare Provider Details

I. General information

NPI: 1326573072
Provider Name (Legal Business Name): DANIEL A HENRIQUEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2017
Last Update Date: 07/02/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 WILLIAM F PALMER RD
MOODUS CT
06469-1132
US

IV. Provider business mailing address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-5220
  • Fax: 860-358-8659
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number067550
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: