Provider Demographics
NPI:1144214552
Name:GREGORY L HENDERSON MD FACS INC
Entity Type:Organization
Organization Name:GREGORY L HENDERSON MD FACS INC
Other - Org Name:FLORIDA EYE SPECIALISTS AND CATARACT INSTITUTE
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:813-681-1122
Mailing Address - Street 1:403 VONDERBURG DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5982
Mailing Address - Country:US
Mailing Address - Phone:813-681-1122
Mailing Address - Fax:813-684-4924
Practice Address - Street 1:135 W ROBERTSON ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5111
Practice Address - Country:US
Practice Address - Phone:813-685-0001
Practice Address - Fax:813-685-0008
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GREGORY L HENDERSON MD FACS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL060983803Medicaid
FL0609838-03Medicaid
FL0609838-03Medicaid
GACI3691Medicare PIN