Provider Demographics
NPI:1801887765
Name:HENDRICKSON, TERRY LANE (OD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:LANE
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 N GARDEN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-2903
Mailing Address - Country:US
Mailing Address - Phone:931-380-2020
Mailing Address - Fax:931-381-5411
Practice Address - Street 1:403 N GARDEN ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-2903
Practice Address - Country:US
Practice Address - Phone:931-380-2020
Practice Address - Fax:931-381-5411
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD-825-T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0243890001OtherPALMETTO
TN2001416OtherBLUE CROSS
TN2001416Medicaid
TN3595176Medicare ID - Type Unspecified
TN2001416Medicaid