Provider Demographics
NPI:1346222890
Name:HENDERSON, EDWARD DANIEL JR (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:DANIEL
Last Name:HENDERSON
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 2106
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-2106
Mailing Address - Country:US
Mailing Address - Phone:601-703-4282
Mailing Address - Fax:601-703-4597
Practice Address - Street 1:9097 COLLINSVILLE RD
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39325-9779
Practice Address - Country:US
Practice Address - Phone:601-626-8874
Practice Address - Fax:601-626-8592
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2013-11-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS16698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
730-14734OtherBLUE CROSS OF AL
MS00121878Medicaid
MS302I087418Medicare PIN
H13223Medicare UPIN