Provider Demographics
NPI:1417933284
Name:HENDERSON, DAVID J (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:J
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:PO BOX 405831
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-5831
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 MEDICAL DR STE 150
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-5085
Practice Address - Country:US
Practice Address - Phone:801-298-3247
Practice Address - Fax:801-298-9675
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1593801205208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT05356Medicaid
UT1518109032Medicaid
UT000066112Medicare PIN
P00719436Medicare PIN
UT005701316Medicare ID - Type Unspecified
UT1518109032Medicaid
D20175Medicare UPIN
UT005536811Medicare ID - Type Unspecified