Provider Demographics
NPI:1598818189
Name:HENDERSON, BRETT R (MD)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:R
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:PO BOX 13668
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88013-3668
Mailing Address - Country:US
Mailing Address - Phone:575-522-1974
Mailing Address - Fax:575-522-5209
Practice Address - Street 1:3850 E LOHMAN AVE
Practice Address - Street 2:SUITE C
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8288
Practice Address - Country:US
Practice Address - Phone:575-522-1974
Practice Address - Fax:575-522-5209
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2015-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2001-213207T00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF1792Medicaid
NMNM019Y53OtherBCBS OF NEW MEXICO
NMP00459212OtherRR MEDICARE
NMH43271Medicare UPIN
NM349703601Medicare PIN
NM6074090001Medicare NSC