Provider Demographics
NPI:1689685489
Name:HENDERSON, RICHARD WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WILLIAM
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:701 N CLAYTON ST
Mailing Address - Street 2:SUITE 510 MEDICAL OFFICE BUILDING
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-3165
Mailing Address - Country:US
Mailing Address - Phone:302-658-8867
Mailing Address - Fax:302-658-9404
Practice Address - Street 1:701 N CLAYTON ST
Practice Address - Street 2:SUITE 510 MEDICAL OFFICE BUILDING
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-3165
Practice Address - Country:US
Practice Address - Phone:302-658-8867
Practice Address - Fax:302-658-9404
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC10002255207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC48738Medicare UPIN
DE407667Medicare PIN
DEC48738Medicare UPIN
DE510064326OtherFEDERAL TAX ID #
DE0000090401Medicaid
DE0000090401OtherDIAMOND ST PTRS #
DE44816OtherCOVENTRY PROVIDER #
DE510064HENOtherBCBSDE PROVIDER #
DEAH2541109OtherDEA #
DEHE407667Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
DEMD1291OtherDE UNIFORM CONT SUB #
DE0098166000OtherAMERIHEALTH/KEYSTONE #
DEC10002255OtherDE MEDICAL LICENSE
DE130OtherSCREENING FOR LIFE
DE367733OtherMAMSI/ALLIANCE/OPCHOICE #
DE407667OtherPERSONAL CHOICE PROV #