Provider Demographics
NPI:1255372868
Name:HENDERSON, MARK T (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
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 1:812 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-2214
Mailing Address - Country:US
Mailing Address - Phone:502-290-2501
Mailing Address - Fax:502-287-1775
Practice Address - Street 1:812 S 3RD ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-2214
Practice Address - Country:US
Practice Address - Phone:502-290-2501
Practice Address - Fax:502-287-1775
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33009207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY33009OtherKENTUCKY LICENSE
KY64330095Medicaid
BH5591804OtherDEA
0645501Medicare ID - Type Unspecified
KY64330095Medicaid