Provider Demographics
NPI:1689840514
Name:HENDERSON, JAMES ALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:ALAN
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J
Other - Middle Name:ALAN
Other - Last Name:HERNDERSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2750 LAUREL ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2038
Mailing Address - Country:US
Mailing Address - Phone:803-254-5171
Mailing Address - Fax:803-779-7403
Practice Address - Street 1:2750 LAUREL ST
Practice Address - Street 2:SUITE 103
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2038
Practice Address - Country:US
Practice Address - Phone:803-254-5171
Practice Address - Fax:803-779-7403
Is Sole Proprietor?:No
Enumeration Date:2008-04-30
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30952207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC309525Medicaid
SC309525Medicaid