Basic Information
| Provider Information | |||||||||
| NPI: | 1306830799 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GREGORY L HENDERSON MD FACS INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FLORIDA EYE SPECIALIST AND CATARACT INSTITUTE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 403 VONDERBURG DR | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115982 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136811122 | ||||||||
| FaxNumber: | 8136844924 | ||||||||
| Practice Location | |||||||||
| Address1: | 612 N TAMIAMI TRL | ||||||||
| Address2: | |||||||||
| City: | RUSKIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335703769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136453831 | ||||||||
| FaxNumber: | 8136454402 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 09/19/2017 | ||||||||
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| AuthorizedOfficialLastName: | HENDERSON | ||||||||
| AuthorizedOfficialFirstName: | GREGORY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8136811122 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GREGORY L HENDERSON MD FACS INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | SR. | ||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology | 152W00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 060983801 | 05 | FL | MEDICAID |