Provider Demographics
NPI:1750473476
Name:HENSON, MARK J (DPM)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:HENSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 S 8TH ST
Mailing Address - Street 2:
Mailing Address - City:GRIFFIN
Mailing Address - State:GA
Mailing Address - Zip Code:30224-4827
Mailing Address - Country:US
Mailing Address - Phone:770-228-6644
Mailing Address - Fax:770-228-5769
Practice Address - Street 1:730 S 8TH ST
Practice Address - Street 2:
Practice Address - City:GRIFFIN
Practice Address - State:GA
Practice Address - Zip Code:30224-4827
Practice Address - Country:US
Practice Address - Phone:770-228-6644
Practice Address - Fax:770-228-5769
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000897213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000871219AMedicaid
GAU81544Medicare UPIN
GA000871219AMedicaid