Provider Demographics
NPI:1619905940
Name:HENDERSON, JOHN P II (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:P
Last Name:HENDERSON
Suffix:II
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 1:70 N STURMER ST
Mailing Address - Street 2:
Mailing Address - City:BELINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26250-7403
Mailing Address - Country:US
Mailing Address - Phone:304-823-2800
Mailing Address - Fax:304-823-2703
Practice Address - Street 1:70 N STURMER ST
Practice Address - Street 2:
Practice Address - City:BELINGTON
Practice Address - State:WV
Practice Address - Zip Code:26250-7403
Practice Address - Country:US
Practice Address - Phone:304-823-2800
Practice Address - Fax:304-823-2703
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV17533207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1802983000Medicaid
WV2028131OtherMEDICARE-TPAN
WV0752973Medicare ID - Type Unspecified