Provider Demographics
NPI:1427226364
Name:LORETTA V HENDERSON, DPM
Entity Type:Organization
Organization Name:LORETTA V HENDERSON, DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:V
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:866-365-3668
Mailing Address - Street 1:PO BOX 720849
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32872-0849
Mailing Address - Country:US
Mailing Address - Phone:866-365-3668
Mailing Address - Fax:407-281-4044
Practice Address - Street 1:1543 ALDERSGATE DR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-6545
Practice Address - Country:US
Practice Address - Phone:866-365-3668
Practice Address - Fax:407-281-4044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2012-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP00001685261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029627900Medicaid
FL87893Medicare PIN
FLT55590Medicare UPIN
FL0704290001Medicare NSC