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General NPI Number Information
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NPI Number | 1417970948
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Entity Type | Individual
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Provider Name | DOUGLAS GLENN HENRICKS M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/25/2006
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Last Update Date | 03/12/2019
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Provider Practice Location Address
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Address Line | 2450 TAMIAMI TRL
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City | PORT CHARLOTTE
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State | FL
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Zip | 33952
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Country | US
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Telephone | 941-624-2704
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Fax | 941-627-6066
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Provider Business Mailing Address
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Address Line | 3434 HANCOCK BRIDGE PKWY STE 301
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City | NORTH FORT MYERS
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State | FL
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Zip | 33903-7099
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Country | US
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Telephone | 877-856-3774
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Fax | 239-599-2612
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | ME0041258
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License Number State | FL
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