Provider Demographics
NPI:1760417216
Name:HENDERSON, ANDREW H III (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:H
Last Name:HENDERSON
Suffix:III
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 1:1221 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2701
Mailing Address - Country:US
Mailing Address - Phone:859-258-4530
Mailing Address - Fax:859-258-4870
Practice Address - Street 1:1221 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2701
Practice Address - Country:US
Practice Address - Phone:859-258-4530
Practice Address - Fax:859-258-4870
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY19017207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY37903705OtherMEDICAID LAB GRP
KY64190176Medicaid
GA110055349OtherRR MEDICARE PIN
KY4000501OtherMEDICARE LAB GRP
GACB5773OtherRR MEDICARE GRP
KY64190176Medicaid