Basic Information
| Provider Information | |||||||||
| NPI: | 1164433298 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | KRISTI | ||||||||
| MiddleName: | DAWN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HENDERSON | ||||||||
| OtherFirstName: | KRISTI | ||||||||
| OtherMiddleName: | MILLER | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 900 N LOUISE ST | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755511725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035562265 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1011 S WILLIAM ST | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | TX | ||||||||
| PostalCode: | 755513245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037962868 | ||||||||
| FaxNumber: | 9037960826 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 01/14/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E-2181 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | K2922 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8F1320 | 01 | TX | BCBS | OTHER | 080181190 | 01 | MEDICARE RR | OTHER | 096544403 | 05 | TX | MEDICAID | 5L214 | 01 | AR | BCBS | OTHER | A013 | 01 | CHAMPUS | OTHER | 119401 | 01 | CHIPS | OTHER |