Provider Demographics
NPI:1669205118
Name:HENDERSON, MICHAEL LAMAR JR (MBA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LAMAR
Last Name:HENDERSON
Suffix:JR
Gender:M
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2728 FISK RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21225-1328
Mailing Address - Country:US
Mailing Address - Phone:410-279-1464
Mailing Address - Fax:
Practice Address - Street 1:2728 FISK RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21225-1328
Practice Address - Country:US
Practice Address - Phone:410-279-1464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD174400000X, 171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No174400000XOther Service ProvidersSpecialist