Provider Demographics
NPI:1164433298
Name:HENDERSON, KRISTI DAWN (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISTI
Middle Name:DAWN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTI
Other - Middle Name:MILLER
Other - Last Name:HENDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:900 N LOUISE ST
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:TX
Mailing Address - Zip Code:75551-1725
Mailing Address - Country:US
Mailing Address - Phone:903-556-2265
Mailing Address - Fax:
Practice Address - Street 1:1011 S WILLIAM ST
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:TX
Practice Address - Zip Code:75551-3245
Practice Address - Country:US
Practice Address - Phone:903-796-2868
Practice Address - Fax:903-796-0826
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-2181207Q00000X
TXK2922207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F1320OtherBCBS
080181190OtherMEDICARE RR
TX096544403Medicaid
AR5L214OtherBCBS
A013OtherCHAMPUS
119401OtherCHIPS
A013OtherCHAMPUS