Provider Demographics
NPI:1982720348
Name:HENDERSON, COLIN JAMES (MD)
Entity Type:Individual
Prefix:
First Name:COLIN
Middle Name:JAMES
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:PO BOX 305
Mailing Address - Street 2:
Mailing Address - City:LA JARA
Mailing Address - State:CO
Mailing Address - Zip Code:81140
Mailing Address - Country:US
Mailing Address - Phone:719-274-0322
Mailing Address - Fax:719-274-0322
Practice Address - Street 1:19021 HWY 285
Practice Address - Street 2:CONEJOS COUNTY HOSPITAL
Practice Address - City:LA JARA
Practice Address - State:CO
Practice Address - Zip Code:81140
Practice Address - Country:US
Practice Address - Phone:719-274-5121
Practice Address - Fax:719-274-6047
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2010-0141207P00000X, 207Q00000X
CO33059207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01330596Medicaid
F44991Medicare UPIN
C489578Medicare ID - Type Unspecified