Provider Demographics
NPI:1639139876
Name:HENDERSON, MARK SHEA (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:SHEA
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 1:135 PLAZA DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:SIKESTON
Mailing Address - State:MO
Mailing Address - Zip Code:63801-5136
Mailing Address - Country:US
Mailing Address - Phone:573-472-6003
Mailing Address - Fax:573-472-7159
Practice Address - Street 1:135 PLAZA DR
Practice Address - Street 2:SUITE 202
Practice Address - City:SIKESTON
Practice Address - State:MO
Practice Address - Zip Code:63801-5136
Practice Address - Country:US
Practice Address - Phone:573-472-6003
Practice Address - Fax:573-472-7159
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4200208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BF145OtherBCBS
TX113358901Medicaid
TX113358905Medicaid
TX113358906Medicaid
TX113358907Medicaid
TX990010000OtherMCARE RR
TX8BF145OtherBCBS
TX0021BPMedicare PIN
TX113358907Medicaid
TX113358901Medicaid
TX8L13372Medicare PIN
8K7942Medicare PIN