Provider Demographics
NPI:1710949417
Name:HENDERSON, KATHRYN ANN (DO)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:ANN
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 MYRTLE ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-7337
Mailing Address - Country:US
Mailing Address - Phone:541-842-7626
Mailing Address - Fax:541-842-7640
Practice Address - Street 1:19 MYRTLE ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-7337
Practice Address - Country:US
Practice Address - Phone:541-842-7626
Practice Address - Fax:541-842-7640
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD013513207P00000X
ORDO13513207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR023507000OtherBC/BS OF OREGON
E68602OtherGROUP HEALTH
CAXPY185059Medicaid
930079054OtherRAILROAD MEDICARE
97520A005OtherCHAMPUS
E68602OtherPROVIDENCE HEALTH PLAN
CAXPY185059Medicaid
R104103Medicare PIN