Provider Demographics
NPI:1679514210
Name:HENDRICKSON, PAUL L (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:L
Last Name:HENDRICKSON
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 1:1027 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3409
Mailing Address - Country:US
Mailing Address - Phone:218-847-5611
Mailing Address - Fax:218-847-0881
Practice Address - Street 1:1027 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3409
Practice Address - Country:US
Practice Address - Phone:218-847-5611
Practice Address - Fax:218-847-0881
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN032152207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN2223OtherSIOUX VALLEY #
MN28232HEOtherMNBS #
MNMN1000020OtherLHS/BANNERHEALTH #
MN901108OtherAMERICA'S PPO/ARAZ #
MN300793600Medicaid
MN0106054OtherMEDICA #
MN10440OtherNDBS #
MN108034OtherUCARE #
MNHP19489OtherHEALTHPARTNERS #
MN0106545OtherMEDICA #
MN16005Medicaid
MNDA9031015654OtherPREFERRED ONE #
MN28232HEOtherMNBS #
MN16005Medicaid
MN300793600Medicaid