Provider Demographics
NPI:1497755680
Name:HENDERSON, WILLIAM W IV (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:W
Last Name:HENDERSON
Suffix:IV
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 1:159 EXECUTIVE DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-4160
Mailing Address - Country:US
Mailing Address - Phone:434-792-4378
Mailing Address - Fax:
Practice Address - Street 1:159 EXECUTIVE DR
Practice Address - Street 2:SUITE F
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-4160
Practice Address - Country:US
Practice Address - Phone:434-792-4378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101035148207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006041710Medicaid
VA290000007Medicare ID - Type Unspecified
VAE34559Medicare UPIN