Provider Demographics
NPI:1609830041
Name:HENDERSON, ROBERT W (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
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 1:2929 CARLISLE ST
Mailing Address - Street 2:SUITE 260
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-1084
Mailing Address - Country:US
Mailing Address - Phone:214-303-1033
Mailing Address - Fax:214-303-1032
Practice Address - Street 1:2929 CARLISLE ST
Practice Address - Street 2:SUITE 260
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-1084
Practice Address - Country:US
Practice Address - Phone:214-303-1033
Practice Address - Fax:214-303-1032
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE0489207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8S1642OtherBC/BS
C16788Medicare UPIN
TXP00371434Medicare PIN
TX8S1642OtherBC/BS