Provider Demographics
NPI:1790963759
Name:HENDERSON, JOSEPH BERNARD (DO)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:BERNARD
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 87112
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-7112
Mailing Address - Country:US
Mailing Address - Phone:412-527-8518
Mailing Address - Fax:910-323-3650
Practice Address - Street 1:2041 VALLEYGATE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3745
Practice Address - Country:US
Practice Address - Phone:910-323-5203
Practice Address - Fax:910-323-3650
Is Sole Proprietor?:No
Enumeration Date:2008-02-01
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-00623207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2013-00623OtherLICENSE #
17953OtherBCBS
NC2013-00623OtherLICENSE #