Provider Demographics
NPI:1578501334
Name:HENDERSON, JOHN WESLEY (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WESLEY
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 1:2910 OLYMPIA DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-3060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1901 SW H K DODGEN LOOP
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-1814
Practice Address - Country:US
Practice Address - Phone:254-771-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF1637207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD66537Medicare UPIN
TX8F0109Medicare PIN
TXP00225513Medicare PIN