Provider Demographics
NPI:1164850657
Name:JOHN M HENDERSON MD FAPA, PLLC
Entity Type:Organization
Organization Name:JOHN M HENDERSON MD FAPA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-617-7913
Mailing Address - Street 1:716 S KOENIGHEIM ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76903-6770
Mailing Address - Country:US
Mailing Address - Phone:325-617-7913
Mailing Address - Fax:325-617-7917
Practice Address - Street 1:716 S KOENIGHEIM ST
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903-6770
Practice Address - Country:US
Practice Address - Phone:443-829-5805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-22
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD4150103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD4150OtherTX MEDICAL LICENSE