Provider Demographics
NPI:1407045339
Name:HENDERSON, THOMAS THOMAN (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:THOMAN
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 1:3410 FAR WEST BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-3194
Mailing Address - Country:US
Mailing Address - Phone:512-427-1100
Mailing Address - Fax:512-427-1208
Practice Address - Street 1:3410 FAR WEST BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-3194
Practice Address - Country:US
Practice Address - Phone:512-427-1100
Practice Address - Fax:512-427-1208
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF4863207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX115509501Medicaid
TX180008032OtherMEDICARE RAILROAD
TXC16791Medicare UPIN
TX115509501Medicaid