Provider Demographics
NPI:1033172705
Name:HENDERSON, MARTHA J (MD)
Entity Type:Individual
Prefix:DR
First Name:MARTHA
Middle Name:J
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 3RD AVE
Mailing Address - Street 2:4C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-9074
Mailing Address - Country:US
Mailing Address - Phone:646-320-2467
Mailing Address - Fax:917-261-7882
Practice Address - Street 1:365 3RD AVE
Practice Address - Street 2:4C
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-9074
Practice Address - Country:US
Practice Address - Phone:646-320-2467
Practice Address - Fax:917-261-7882
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY214056-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02439141Medicaid
NYH30960Medicare UPIN
NY02439141Medicaid