Provider Demographics
NPI:1972673838
Name:HENDERSON, ROBERT C (MD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:C
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 N HABANA AVE STE 30
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-7123
Mailing Address - Country:US
Mailing Address - Phone:813-879-6603
Mailing Address - Fax:813-879-6805
Practice Address - Street 1:4600 N HABANA AVE STE 30
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33614-7123
Practice Address - Country:US
Practice Address - Phone:813-879-6603
Practice Address - Fax:813-879-6805
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0036678174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067431100Medicaid
FL30306Medicare PIN
FL067431100Medicaid