Provider Demographics
NPI:1689986721
Name:HENDERSON, NICHOLAS ELLIOTT (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ELLIOTT
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 1:4434 BRADLEY AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32839-1419
Mailing Address - Country:US
Mailing Address - Phone:443-804-6723
Mailing Address - Fax:
Practice Address - Street 1:3211 ROUSE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-2117
Practice Address - Country:US
Practice Address - Phone:443-804-6723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 120324208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation