Healthcare Provider Details

I. General information

NPI: 1558333179
Provider Name (Legal Business Name): DOUGLAS K HENSTROM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWKINS DR
IOWA CITY IA
52242-1007
US

IV. Provider business mailing address

2255 N 1700 W STE 200
LAYTON UT
84041-1187
US

V. Phone/Fax

Practice location:
  • Phone: 319-356-3600
  • Fax: 319-356-4547
Mailing address:
  • Phone: 801-776-2220
  • Fax: 801-820-2772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number47669
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number39672
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number39672
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number39672
License Number StateIA
# 5
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number10222796-1205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: