Healthcare Provider Details

I. General information

NPI: 1467406561
Provider Name (Legal Business Name): MARK A. HENLEY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 12/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

IV. Provider business mailing address

PO BOX 79137
BALTIMORE MD
21279-0137
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7456
  • Fax: 757-668-9255
Mailing address:
  • Phone: 757-668-7200
  • Fax: 757-668-9691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101045119
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number0101045119
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: