Provider Demographics
NPI:1689040305
Name:HENDERSAON, GEORGE GRIFFIN SR
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:GRIFFIN
Last Name:HENDERSAON
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48739 FAR CRY RD
Mailing Address - Street 2:P.O. BOX 1291
Mailing Address - City:LEXINGTON PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20653-3055
Mailing Address - Country:US
Mailing Address - Phone:301-862-9098
Mailing Address - Fax:301-645-2926
Practice Address - Street 1:48739 FAR CRY RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON PARK
Practice Address - State:MD
Practice Address - Zip Code:20653-3055
Practice Address - Country:US
Practice Address - Phone:301-862-9098
Practice Address - Fax:301-645-2926
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDUD1209171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist