Provider Demographics
NPI:1588676597
Name:HENDERSON, JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1505 SPRINGRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-3231
Mailing Address - Country:US
Mailing Address - Phone:601-957-8494
Mailing Address - Fax:601-482-8311
Practice Address - Street 1:1201 22ND AVE STE C
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4010
Practice Address - Country:US
Practice Address - Phone:601-484-5876
Practice Address - Fax:601-482-8311
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS15783207P00000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G86797Medicare UPIN