Provider Demographics
NPI:1477597979
Name:HENDERSON, JOHN M SR (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:HENDERSON
Suffix:SR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 10TH AVE SUITE 320
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901
Mailing Address - Country:US
Mailing Address - Phone:706-323-5717
Mailing Address - Fax:706-323-6010
Practice Address - Street 1:1900 10TH AVE SUITE 320
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901
Practice Address - Country:US
Practice Address - Phone:706-323-5717
Practice Address - Fax:855-681-1414
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025765207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA025765OtherSTATE LICENSE
GAAH2421751OtherDEA
GAD45629Medicare UPIN
GAAH2421751OtherDEA