Provider Demographics
NPI:1245201789
Name:HENDERSON, MARILYN C (DPM)
Entity Type:Individual
Prefix:
First Name:MARILYN
Middle Name:C
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:882 MILLERSVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603
Mailing Address - Country:US
Mailing Address - Phone:717-291-0391
Mailing Address - Fax:717-291-0832
Practice Address - Street 1:882 MILLERSVILLE RD
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17603-6154
Practice Address - Country:US
Practice Address - Phone:717-291-0391
Practice Address - Fax:717-291-0832
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002642L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1681042Medicaid
PA1681042Medicaid
T72784Medicare UPIN