Provider Demographics
NPI:1962630434
Name:HENDERSON, KATHRYN R (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:R
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:R
Other - Last Name:MORAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 23340
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63156-3340
Mailing Address - Country:US
Mailing Address - Phone:314-843-7333
Mailing Address - Fax:314-843-9946
Practice Address - Street 1:5034 GRIFFIN RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-3418
Practice Address - Country:US
Practice Address - Phone:314-843-7333
Practice Address - Fax:314-843-9946
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012026899207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO124510057Medicare PIN