Provider Demographics
NPI:1356452395
Name:HENDERSON, JOHN M (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
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 1:1400 W TRENTON RD
Mailing Address - Street 2:
Mailing Address - City:EDINBURG
Mailing Address - State:TX
Mailing Address - Zip Code:78539-3413
Mailing Address - Country:US
Mailing Address - Phone:956-388-2207
Mailing Address - Fax:
Practice Address - Street 1:1636 HUNTERS GLEN RD
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-5008
Practice Address - Country:US
Practice Address - Phone:325-949-5722
Practice Address - Fax:325-947-2054
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD41502084P0800X, 2084F0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084F0202XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyForensic Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX216481603Medicaid
TX8DP652OtherBCBS TX
TX268422YKSJMedicare PIN