Provider Demographics
NPI:1023033271
Name:HENDERSON, STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:HENDERSON
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:PO BOX 240086
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-9186
Mailing Address - Country:US
Mailing Address - Phone:310-445-2800
Mailing Address - Fax:310-445-2983
Practice Address - Street 1:1516 COTNER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3303
Practice Address - Country:US
Practice Address - Phone:310-445-2800
Practice Address - Fax:310-445-2983
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG660992085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G660990Medicaid
CA00G660990OtherBLUE SHIELD
CAWG66099DMedicare PIN
CAWG66099EMedicare PIN
CATP018Medicare PIN
CAWA66099GMedicare PIN
CATG054Medicare PIN
CAG38794Medicare UPIN
CABC606XMedicare PIN
CATG056Medicare PIN
CAWG66099BMedicare PIN
CAWG66099CMedicare PIN
CABC606WMedicare PIN
CA00G660990OtherBLUE SHIELD
CAWG66099FMedicare PIN