Provider Demographics
NPI:1033146725
Name:HENDERSON, EVA MAE (MD)
Entity Type:Individual
Prefix:DR
First Name:EVA
Middle Name:MAE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:EVA
Other - Middle Name:HENDERSON
Other - Last Name:CAMARA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 3437
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39207-3437
Mailing Address - Country:US
Mailing Address - Phone:601-362-5321
Mailing Address - Fax:601-354-5159
Practice Address - Street 1:350 W WOODROW WILSON AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39213-7681
Practice Address - Country:US
Practice Address - Phone:601-709-5150
Practice Address - Fax:601-709-5151
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10119208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1692743Medicaid
MS00116298Medicaid
MS512I370057Medicare PIN