Healthcare Provider Details

I. General information

NPI: 1184986267
Provider Name (Legal Business Name): KARL JOHN HENRIKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2223 LIME KILN RD STE 1
GREEN BAY WI
54311-6213
US

IV. Provider business mailing address

2223 LIME KILN RD STE 1
GREEN BAY WI
54311-6213
US

V. Phone/Fax

Practice location:
  • Phone: 920-430-8113
  • Fax: 920-430-8122
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMT201601
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number71031
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: