Provider Demographics
NPI:1750353223
Name:HENDERSON, JAMES G (MD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:G
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 1:3415 53RD AVE
Mailing Address - Street 2:
Mailing Address - City:BETTENDORF
Mailing Address - State:IA
Mailing Address - Zip Code:52722-6976
Mailing Address - Country:US
Mailing Address - Phone:563-742-4370
Mailing Address - Fax:309-558-7026
Practice Address - Street 1:3415 53RD AVE
Practice Address - Street 2:
Practice Address - City:BETTENDORF
Practice Address - State:IA
Practice Address - Zip Code:52722-6976
Practice Address - Country:US
Practice Address - Phone:563-742-4370
Practice Address - Fax:309-558-7026
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33996207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA40379OtherWELLMARK
IA1750353223Medicaid
IAP01170195OtherRR MEDICARE
IA40379OtherWELLMARK
IA1750353223Medicaid