Provider Demographics
NPI:1154327856
Name:HENDERSON, JOHNATHAN EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:EDWARD
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 1:420 E 2ND AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30161-3210
Mailing Address - Country:US
Mailing Address - Phone:706-509-3000
Mailing Address - Fax:
Practice Address - Street 1:304 SHORTER AVE NW STE 201
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165
Practice Address - Country:US
Practice Address - Phone:706-509-3300
Practice Address - Fax:706-509-3301
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-27
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054898207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0103487OtherUNITED HEALTHCARE
GAP00177381OtherRAILROAD RETIREMENT MEDIC
GA6313OtherKAISER PERMANENTE
GA388021OtherBCBS
GA0103487OtherUNITED HEALTHCARE
GAP00177381OtherRAILROAD RETIREMENT MEDIC