Provider Demographics
NPI:1275648750
Name:HENDERSON, RAYMOND SR (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:
Last Name:HENDERSON
Suffix:SR
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 1:2234 COLONIAL BLVD
Mailing Address - Street 2:ATTN: PAYER CONTRACTING & RELATIONS DEPT.
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1412
Mailing Address - Country:US
Mailing Address - Phone:239-931-7342
Mailing Address - Fax:239-931-7385
Practice Address - Street 1:1411 N FLAGLER DR
Practice Address - Street 2:SUITE 7300
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33401-3404
Practice Address - Country:US
Practice Address - Phone:561-804-9898
Practice Address - Fax:561-804-9049
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME59588208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP1024914OtherFREEDOM
FL4510159OtherAETNA
FL221891OtherAVMED
FL055398100Medicaid
FL1022165OtherCAREPLUS
FL1605100OtherCIGNA
FLP01591843OtherRR MEDICARE
FLP963010OtherOPTIMUM
FL03303OtherWELLCARE
FL12883OtherBCBS
FL2886OtherDIMENSION
FL1022165OtherCAREPLUS
FL221891OtherAVMED
FL12883XMedicare PIN