Provider Demographics
NPI:1043658677
Name:HENDERSON, BENNETT ELLEN HARGROVE (MD)
Entity Type:Individual
Prefix:DR
First Name:BENNETT
Middle Name:ELLEN HARGROVE
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 1:2215 NASHVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1105
Mailing Address - Country:US
Mailing Address - Phone:806-725-5844
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:4102 24TH ST STE 406
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1804
Practice Address - Country:US
Practice Address - Phone:806-725-5790
Practice Address - Fax:806-725-5791
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
TXQ9635207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8GX035OtherBCBS TX
TX582317YKT8OtherTX MEDICARE
TX373353701Medicaid
NM1043658677OtherBCBS NM CENTENNIAL
NM44159340Medicaid
TX1043658677OtherFIRSTCARE