Provider Demographics
NPI:1700879848
Name:HENDERSON, RANDALL DALE (DO)
Entity Type:Individual
Prefix:DR
First Name:RANDALL
Middle Name:DALE
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2177
Mailing Address - Street 2:
Mailing Address - City:WHITNEY
Mailing Address - State:TX
Mailing Address - Zip Code:76692-5177
Mailing Address - Country:US
Mailing Address - Phone:254-694-3621
Mailing Address - Fax:254-694-7436
Practice Address - Street 1:1314 N BRAZOS ST
Practice Address - Street 2:
Practice Address - City:WHITNEY
Practice Address - State:TX
Practice Address - Zip Code:76692-2010
Practice Address - Country:US
Practice Address - Phone:254-694-3621
Practice Address - Fax:254-694-7436
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL1340207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159121604Medicaid
TX159121604Medicaid
TX354833ZHCWMedicare PIN