MEDICARE: DR. CLYDE HENKE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	E4399	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	8U8630	OTHER	TX	BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770545386
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CLYDE HENKE MD

Provider Business Mailing Address
First Line	:	3501 KNICKERBOCKER RD
Second Line	:	WILLIAMS FAMILY CENTER
City	:	SAN ANGELO
State	:	TX
Zip	:	76904-7610
Country	:	US
Telephone Number	:	325-245-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3501 KNICKERBOCKER RD
Second Line	:	WILLIAMS FAMILY CENTER
City	:	SAN ANGELO
State	:	TX
Zip	:	76904-7610
Country	:	US
Telephone Number	:	325-245-4000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2006
Last Update Date	:	06/05/2012

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