Provider Demographics
NPI:1346654407
Name:HENDERSON, JOHN IV (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:HENDERSON
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:790 LAKE FRANCES DR APT 5
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-4337
Mailing Address - Country:US
Mailing Address - Phone:678-447-3683
Mailing Address - Fax:
Practice Address - Street 1:1327 STADIUM DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31207-1302
Practice Address - Country:US
Practice Address - Phone:478-301-2382
Practice Address - Fax:478-301-2391
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCLL36863207R00000X
GA078835207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine