Provider Demographics
NPI:1649217746
Name:HENDERSON, BRENT (DO)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 N ASPEN AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-1197
Mailing Address - Country:US
Mailing Address - Phone:918-794-6008
Mailing Address - Fax:918-516-3447
Practice Address - Street 1:8801 S 101ST EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5716
Practice Address - Country:US
Practice Address - Phone:918-294-4915
Practice Address - Fax:918-294-4947
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3954207L00000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200059770AMedicaid
OK900522349OtherMEDICARE GROUP PIN
OK200059770AMedicaid
OKI42324Medicare UPIN