Provider Demographics
NPI:1821539230
Name:HENDERSON, ERNESTO (DO)
Entity Type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1096 PRESIDENT ST APT 34
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-1442
Mailing Address - Country:US
Mailing Address - Phone:301-442-1195
Mailing Address - Fax:813-550-1162
Practice Address - Street 1:506 6TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3609
Practice Address - Country:US
Practice Address - Phone:929-522-8129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-17
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDH0089118204D00000X, 2084P0800X
VA0102206033204D00000X, 2084P0800X
NY308770204D00000X, 2084P0800X, 2084P0804X
DCDO034809204D00000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry