Provider Demographics
NPI:1922165703
Name:HENDRICKS, DOUGLAS L (MD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:L
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DOUGLAS
Other - Middle Name:L
Other - Last Name:HENDRICKS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:280 NEWPORT CENTER DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7526
Mailing Address - Country:US
Mailing Address - Phone:949-640-9570
Mailing Address - Fax:949-640-9569
Practice Address - Street 1:280 NEWPORT CENTER DR
Practice Address - Street 2:SUITE 120
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7526
Practice Address - Country:US
Practice Address - Phone:949-640-9570
Practice Address - Fax:949-640-9569
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG0694212082S0105X, 208200000X
IL036151135208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1922165703Medicaid
IL036151135Medicaid