Provider Demographics
NPI:1164427621
Name:HENDERSON, RALPH JONATHAN (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:JONATHAN
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 1:255 BERT KOUNS LOOP
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-8150
Mailing Address - Country:US
Mailing Address - Phone:318-683-0411
Mailing Address - Fax:318-603-5461
Practice Address - Street 1:255 BERT KOUNS
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106
Practice Address - Country:US
Practice Address - Phone:318-683-0411
Practice Address - Fax:318-603-5461
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021340208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1924075Medicaid
LA340019771OtherRAILROAD MEDICARE
LA5N862Medicare PIN
LA1924075Medicaid