Provider Demographics
NPI:1871684274
Name:HENDERSON, BETH A (OD)
Entity Type:Individual
Prefix:DR
First Name:BETH
Middle Name:A
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:OD
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Mailing Address - Street 1:1 UNIVERSITY BLVD
Mailing Address - Street 2:PATIENT CARE CENTER
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121-4400
Mailing Address - Country:US
Mailing Address - Phone:314-516-5131
Mailing Address - Fax:314-516-5507
Practice Address - Street 1:7840 NATURAL BRIDGE RD
Practice Address - Street 2:PATIENT CARE CENTER
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121-4617
Practice Address - Country:US
Practice Address - Phone:314-516-5131
Practice Address - Fax:314-516-5507
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOT03067152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1871684274Medicaid
MO029007473Medicare PIN
MO1871684274Medicaid
MO991630004Medicare PIN
MO067820017Medicare PIN