Individual
DR. ROBERT EMMETT HENRY III
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
M.D., M.S.
Contact information
Practice address
558 SAINT CHARLES DR, SUITE 200, THOUSAND OAKS, CA 91360-3903
(805) 379-2322
(805) 379-2373
Mailing address
100-7 RANCH ROAD, 348, THOUSAND OAKS, CA 91362-6017
(805) 497-4414
Taxonomy
Speciality
Code
Description
License number
State
204C00000X
Sports Medicine (Neuromusculoskeletal Medicine) Physician
GO74794
CA
208100000X
Physical Medicine & Rehabilitation Physician
Primary
GO74794
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
CC801Y
ADDITIONAL PTAN
CA
01
—
CC801Z
PTAN
CA
01
—
WG74794E
MEDICARE PTAN
CA
Enumeration date
03/15/2007
Last updated
10/26/2015
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