Provider Demographics
NPI:1205868338
Name:HENSON, KENNETH I (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:I
Last Name:HENSON
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 1:8650 SUDLEY ROAD
Mailing Address - Street 2:# 206
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20110
Mailing Address - Country:US
Mailing Address - Phone:703-368-9234
Mailing Address - Fax:703-368-0505
Practice Address - Street 1:8650 SUDLEY ROAD
Practice Address - Street 2:# 206
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110
Practice Address - Country:US
Practice Address - Phone:703-368-9234
Practice Address - Fax:703-368-0505
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049560208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI210992OtherANTHEM BCBS
VI210992OtherANTHEM BCBS