Provider Demographics
NPI:1013250182
Name:HENDERSON, NATHAN RAY (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:RAY
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 1:8970 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:AR
Mailing Address - Zip Code:72837-9110
Mailing Address - Country:US
Mailing Address - Phone:479-331-3880
Mailing Address - Fax:479-331-3788
Practice Address - Street 1:8970 MARKET ST
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:AR
Practice Address - Zip Code:72837-9110
Practice Address - Country:US
Practice Address - Phone:479-331-3880
Practice Address - Fax:479-331-3788
Is Sole Proprietor?:No
Enumeration Date:2013-03-27
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE8951207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR210379001Medicaid
AR438034YJS9Medicare PIN