Provider Demographics
NPI:1689653560
Name:HENDERSON, DONALD W (MD)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:W
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 1:3306 LAKE ARIEL HWY
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-7685
Mailing Address - Country:US
Mailing Address - Phone:570-253-0148
Mailing Address - Fax:570-251-7816
Practice Address - Street 1:3306 LAKE ARIEL HWY
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-7685
Practice Address - Country:US
Practice Address - Phone:570-253-0148
Practice Address - Fax:570-251-7816
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD020397E207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1000337Medicaid
PA026285Medicare PIN
PA1000337Medicaid