Provider Demographics
NPI:1235347428
Name:HENDERSON, WINNIE W (MD, PHD)
Entity Type:Individual
Prefix:
First Name:WINNIE
Middle Name:W
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3783 INTERNATIONAL CT STE 200
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-1025
Mailing Address - Country:US
Mailing Address - Phone:541-735-3778
Mailing Address - Fax:541-735-3772
Practice Address - Street 1:3783 INTERNATIONAL CT STE 200
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-1025
Practice Address - Country:US
Practice Address - Phone:541-735-3778
Practice Address - Fax:541-735-3772
Is Sole Proprietor?:No
Enumeration Date:2007-05-19
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD150994208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500621661Medicaid
ORR154638Medicare PIN