Provider Demographics
NPI:1578624573
Name:HENDERSON, DONALD WADE (OD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:WADE
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 S KOBE MILL ED
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711
Mailing Address - Country:US
Mailing Address - Phone:217-698-9477
Mailing Address - Fax:217-698-9474
Practice Address - Street 1:2709 S KOBE MILL ED
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711
Practice Address - Country:US
Practice Address - Phone:217-698-9477
Practice Address - Fax:217-698-9474
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009151152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL211128Medicare ID - Type Unspecified
ILK15346Medicare UPIN