Provider Demographics
NPI:1700813227
Name:HENDERSON, JUDY D (MD)
Entity Type:Individual
Prefix:DR
First Name:JUDY
Middle Name:D
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6572 RED ARROW HWY
Mailing Address - Street 2:
Mailing Address - City:COLOMA
Mailing Address - State:MI
Mailing Address - Zip Code:49038-8700
Mailing Address - Country:US
Mailing Address - Phone:269-202-7014
Mailing Address - Fax:269-202-7130
Practice Address - Street 1:6572 RED ARROW HWY
Practice Address - Street 2:
Practice Address - City:COLOMA
Practice Address - State:MI
Practice Address - Zip Code:49038-8700
Practice Address - Country:US
Practice Address - Phone:269-202-7014
Practice Address - Fax:269-202-7130
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301088108207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0111108OtherBCBS
MI1101111081OtherBLUE CROS BLUE SHIELD
MI1700813227Medicaid
MIH06000080Medicare PIN
MI1101111081OtherBLUE CROS BLUE SHIELD
MI1101111081OtherBLUE CROS BLUE SHIELD
MIH06000080Medicare PIN