Provider Demographics
NPI:1700989001
Name:HENDERSON, DIANE JOYCE (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:JOYCE
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2300 S FLOWER ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90007-2677
Mailing Address - Country:US
Mailing Address - Phone:213-742-1433
Mailing Address - Fax:213-742-1496
Practice Address - Street 1:2300 S FLOWER ST
Practice Address - Street 2:SUITE 300
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-2660
Practice Address - Country:US
Practice Address - Phone:213-742-1433
Practice Address - Fax:213-742-1496
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG220202080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral Pediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G220200OtherMEDI-CAL NUMBER
CACGP168503OtherCCS PROVIDER NUMBER