Provider Demographics
NPI:1356873665
Name:HENDERSON, DAVID EDWARD (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:EDWARD
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:P.O. BOX 550
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:AR
Mailing Address - Zip Code:72745
Mailing Address - Country:US
Mailing Address - Phone:479-463-7775
Mailing Address - Fax:479-463-7187
Practice Address - Street 1:813 FOUNDERS PARK DRIVE.
Practice Address - Street 2:SUITE 203
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762
Practice Address - Country:US
Practice Address - Phone:479-463-2440
Practice Address - Fax:479-463-2465
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ARE-15375207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program