Active NPI
Douglas Glenn Henricks, M.D.
- Internal Medicine Physician
- Port Charlotte, FL
National Provider Identifier
1417970948
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Internal Medicine Physician
- License
- ME0041258
- Practice address
- 2450 Tamiami TRL
Port Charlotte, FL 33952 - Phone
- (941) 624-2704
- Fax
- (941) 627-6066
- NPI assigned
- Jul 25, 2006
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Internal Medicine Physician | 207R00000X | ME0041258 | FL | Primary |
Addresses
Primary practice location
2450 Tamiami TRL
Port Charlotte, FL 33952
Mailing address
3434 Hancock Bridge Pkwy Ste 301
North Fort Myers, FL 33903-7099
Phone (877) 856-3774
Other practice location 1
6311 S Pointe Blvd
Fort Myers, FL 33919-4901
Phone (239) 275-0040 ext. 206
Other practice location 2
6311 S Pointe Blvd
Fort Myers, FL 33919-4901
Phone (239) 275-0040 ext. 206
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 36367V | Other | FL | UNSPECIFIED |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| ME0041258 | FL | MD | Internal Medicine Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1153785600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1552348800000",
"number": "1417970948",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "3434 HANCOCK BRIDGE PKWY STE 301",
"city": "NORTH FORT MYERS",
"state": "FL",
"postal_code": "339037099",
"telephone_number": "877-856-3774",
"fax_number": "239-599-2612"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2450 TAMIAMI TRL",
"city": "PORT CHARLOTTE",
"state": "FL",
"postal_code": "33952",
"telephone_number": "941-624-2704",
"fax_number": "941-627-6066"
}
],
"practiceLocations": [
{
"address_1": "6311 S Pointe Blvd",
"address_purpose": "LOCATION",
"city": "Fort Myers",
"state": "FL",
"postal_code": "339194901",
"country_code": "US",
"telephone_number": "239-275-0040 x206",
"fax_number": "239-275-7997",
"country_name": "United States",
"address_type": "DOM"
},
{
"address_1": "6311 S Pointe Blvd",
"address_purpose": "LOCATION",
"city": "Fort Myers",
"state": "FL",
"postal_code": "339194901",
"country_code": "US",
"telephone_number": "239-275-0040 x206",
"fax_number": "239-275-7997",
"country_name": "United States",
"address_type": "DOM"
}
],
"basic": {
"last_name": "HENRICKS",
"first_name": "DOUGLAS",
"middle_name": "GLENN",
"credential": "M.D.",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-07-25",
"last_updated": "2019-03-12",
"status": "A"
},
"taxonomies": [
{
"code": "207R00000X",
"taxonomy_group": "",
"desc": "Internal Medicine",
"state": "FL",
"license": "ME0041258",
"primary": true
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "UNSPECIFIED",
"identifier": "36367V",
"state": "FL"
}
],
"endpoints": [],
"other_names": []
}Other providers in Port Charlotte, FL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 12, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.