Provider Demographics
NPI:1437165958
Name:HENDERSON, JOEL M (MD)
Entity Type:Individual
Prefix:
First Name:JOEL
Middle Name:M
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 1:720 HARRISON AVE
Mailing Address - Street 2:DOB 503
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:670 ALBANY STREET
Practice Address - Street 2:SUITE 304
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118-2518
Practice Address - Country:US
Practice Address - Phone:617-414-7063
Practice Address - Fax:617-414-5315
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA219886207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2077060Medicaid
A37451Medicare UPIN