Provider Demographics
NPI:1669817011
Name:HENDERSON, LAUREN I (MD)
Entity Type:Individual
Prefix:MS
First Name:LAUREN
Middle Name:I
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:HENDERSON
Other - Last Name:LOMAX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-521-6097
Mailing Address - Fax:
Practice Address - Street 1:2525 CUMBERLAND PKWY SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-3915
Practice Address - Country:US
Practice Address - Phone:404-365-0966
Practice Address - Fax:404-431-4330
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-29
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA148084207N00000X
GA86208207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000969672Medicaid