Provider Demographics
NPI:1881770527
Name:HENDRICKSON EYE CLINIC PA
Entity type:Organization
Organization Name:HENDRICKSON EYE CLINIC PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:OLEN
Authorized Official - Last Name:HENDRICKSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:501-329-1151
Mailing Address - Street 1:701 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72034
Mailing Address - Country:US
Mailing Address - Phone:501-329-1151
Mailing Address - Fax:501-329-2498
Practice Address - Street 1:701 LOCUST ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034
Practice Address - Country:US
Practice Address - Phone:501-329-1151
Practice Address - Fax:501-329-2498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC4491207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
52306Medicare ID - Type Unspecified
D79488Medicare UPIN