Provider Demographics
NPI:1275521452
Name:HENDERSON, VINCENT CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:CHARLES
Last Name:HENDERSON
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 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:3575 PORTAGE RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-6092
Practice Address - Country:US
Practice Address - Phone:574-647-4530
Practice Address - Fax:574-647-4531
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033656A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000588530OtherBCBS BMG E BLAIR WARNER
IN080073934OtherRR MEDICARE
IN000000085144OtherBCBS BMG MAIN ST
IN200064640Medicaid
IN000000085145OtherBCBS BMG MEDPOINT IRELAND
IN000000319907OtherBCBS BMG PORTAGE RD
INE56426Medicare UPIN
IN000000588530OtherBCBS BMG E BLAIR WARNER
IN236040MMMedicare PIN
IN247000BMedicare PIN
INM400039250Medicare PIN