Provider Demographics
NPI:1689792624
Name:COREY H. HENDERSON MD PA
Entity Type:Organization
Organization Name:COREY H. HENDERSON MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:H
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-221-1706
Mailing Address - Street 1:PO BOX 1409
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32727-1409
Mailing Address - Country:US
Mailing Address - Phone:352-742-7735
Mailing Address - Fax:
Practice Address - Street 1:1000 WATERMAN WAY
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778
Practice Address - Country:US
Practice Address - Phone:407-886-8164
Practice Address - Fax:407-475-0280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4573Medicare ID - Type Unspecified