Basic Information
| Provider Information | |||||||||
| NPI: | 1245225309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | VICTOR | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2200 E SHOW LOW LAKE RD | ||||||||
| Address2: | |||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285376978 | ||||||||
| FaxNumber: | 9285374205 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 E HUNT DR | ||||||||
| Address2: | STE H | ||||||||
| City: | SHOW LOW | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9285376964 | ||||||||
| FaxNumber: | 9285328798 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 12/30/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 26987 | AZ | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 440264 | 01 | AZ | AHCCCS | OTHER | BH2334390 | 01 | AZ | DEA | OTHER |