Provider Demographics
NPI:1487694493
Name:HENKE, WILLIAM C (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:C
Last Name:HENKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3409
Mailing Address - Country:US
Mailing Address - Phone:218-847-5611
Mailing Address - Fax:218-847-0881
Practice Address - Street 1:1027 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3409
Practice Address - Country:US
Practice Address - Phone:218-847-5611
Practice Address - Fax:218-847-0881
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5010207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN281808600Medicaid
MNDA9031015663OtherPREFERRED ONE #
MN16651Medicaid
MN124772OtherUCARE #
MN23630HEOtherMNBS #
MNMN100021OtherLHS/BANNERHEALTH #
MN0106052OtherMEDICA #
ND1277OtherNDBS #
MN6404OtherMNBS #
MN598579OtherAMERICA'S PPO/ARAZ #
MN0122661OtherMEDICA #
MN598579OtherAMERICA'S PPO/ARAZ #
FMD65003Medicare UPIN
MN6404OtherMNBS #
ND1277Medicare ID - Type UnspecifiedNDBS #