Provider Demographics
NPI:1649231291
Name:HENDERSON, RANDAL HOLLIS (MD)
Entity Type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:HOLLIS
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:P. O. BOX 116304
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-6304
Mailing Address - Country:US
Mailing Address - Phone:904-588-1800
Mailing Address - Fax:
Practice Address - Street 1:2015 N. JEFFERSON ST.
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206
Practice Address - Country:US
Practice Address - Phone:904-588-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME366772085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2552299-00Medicaid
GA000432264GMedicaid
FL92000669Medicare PIN
FL2552299-00Medicaid
GA000432264GMedicaid