Provider Demographics
NPI:1417953118
Name:HENDERSON, LEE ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:ALLEN
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 5628
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-5628
Mailing Address - Country:US
Mailing Address - Phone:765-448-4319
Mailing Address - Fax:765-448-2921
Practice Address - Street 1:2400 SOUTH ST.
Practice Address - Street 2:DEPARTMENT OF PATHOLOGY
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904
Practice Address - Country:US
Practice Address - Phone:765-448-4319
Practice Address - Fax:765-448-2921
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1035929A207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000315528OtherANTHEM
IN111890JOtherMEDICARE
IN176600GOtherMEDICARE
IN000000315528OtherANTHEM
INCA8380Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE