Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204C00000X | Sports Medicine Doctor | GO74794 | CA |
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | GO74794 | CA |
NPI | 1306970900 |
---|---|
Provider Name | Dr. Robert Emmett Henry III |
First Address | Thousand Oaks, CA 91362-6017 |
Second Address | Thousand Oaks, CA 91360-3903 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/03/2007 |
Last Update Date | 26/10/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
CC801Y | ADDITIONAL PTAN (01) | CA |
CC801Z | PTAN (01) | CA |
WG74794E | MEDICARE PTAN (01) | CA |