Provider Demographics
NPI:1407817489
Name:HENDERSON, HATTIE E (MD)
Entity Type:Individual
Prefix:
First Name:HATTIE
Middle Name:E
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-8326
Mailing Address - Country:US
Mailing Address - Phone:903-596-0602
Mailing Address - Fax:903-596-0620
Practice Address - Street 1:820 E FRONT ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8326
Practice Address - Country:US
Practice Address - Phone:903-596-0602
Practice Address - Fax:903-596-0620
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL5762207Q00000X, 207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165297602Medicaid
TX421441YM6QMedicare PIN
TX165297602Medicaid