Provider Demographics
NPI:1720038243
Name:HENDERSON, LORETTA V (DPM)
Entity Type:Individual
Prefix:DR
First Name:LORETTA
Middle Name:V
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 720849
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32872-0849
Mailing Address - Country:US
Mailing Address - Phone:407-518-7747
Mailing Address - Fax:407-518-9009
Practice Address - Street 1:1508 VILLAGE OAK LN
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-6558
Practice Address - Country:US
Practice Address - Phone:407-518-7747
Practice Address - Fax:407-518-9009
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1685213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL029627900Medicaid
FL87893OtherBCBS
FL0704290001Medicare NSC
FL029627900Medicaid
FL87893Medicare PIN