Provider Demographics
NPI:1407804859
Name:HENDERSON, GREGORY S (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:S
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2171
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310-0368
Mailing Address - Country:US
Mailing Address - Phone:360-792-6731
Mailing Address - Fax:360-792-6561
Practice Address - Street 1:2520 CHERRY AVE
Practice Address - Street 2:PATHOLOGY DEPARTMENT
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-4229
Practice Address - Country:US
Practice Address - Phone:360-792-6731
Practice Address - Fax:360-792-6561
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00048144207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1722111Medicaid
G54789Medicare UPIN
LA1722111Medicaid