Provider Demographics
NPI:1841477239
Name:MICHAEL D HENDERSON D O LLC
Entity type:Organization
Organization Name:MICHAEL D HENDERSON D O LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:D
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:541-330-6003
Mailing Address - Street 1:2855 NW CROSSING DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7049
Mailing Address - Country:US
Mailing Address - Phone:541-330-6003
Mailing Address - Fax:
Practice Address - Street 1:2855 NW CROSSING DR
Practice Address - Street 2:SUITE 101
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7049
Practice Address - Country:US
Practice Address - Phone:541-330-6003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-28
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO25674207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287780Medicaid
ORI33184Medicare UPIN
OR141170Medicare PIN
OR287780Medicaid
OR131829Medicare PIN
OR130669Medicare PIN
OR142136Medicare PIN