Provider Demographics
NPI:1114135118
Name:HENDERSON, BARRY MERLE (MD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:MERLE
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 1:3634 SUSSEX DR NE
Mailing Address - Street 2:
Mailing Address - City:MILLEDGEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31061-9339
Mailing Address - Country:US
Mailing Address - Phone:478-445-6774
Mailing Address - Fax:
Practice Address - Street 1:RIVERS STATE PRISON
Practice Address - Street 2:MEDICAL DEPARTMENT
Practice Address - City:HARDWICK
Practice Address - State:GA
Practice Address - Zip Code:31034-1500
Practice Address - Country:US
Practice Address - Phone:478-445-6774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016246208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD45631Medicare UPIN