Provider Demographics
NPI:1427002336
Name:HENDERSON, RICHARD A (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
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 1:3420 22ND PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1314
Mailing Address - Country:US
Mailing Address - Phone:806-725-5844
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:9812 SLIDE RD
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-5781
Practice Address - Country:US
Practice Address - Phone:806-725-8400
Practice Address - Fax:806-783-3031
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK5115207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX040597904Medicaid
TX100171102OtherFIRSTCARE PROVIDER #
TX8A8527OtherBCBS TX
TX100171102OtherFIRSTCARE PROVIDER #
TX8A8527OtherBCBS TX
TX040597904Medicaid