Basic Information
| Provider Information | |||||||||
| NPI: | 1376982074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | MELISSA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2968 | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465152968 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742963200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2222 W LEXINGTON AVE | ||||||||
| Address2: | |||||||||
| City: | ELKHART | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465141420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742943030 | ||||||||
| FaxNumber: | 5742963544 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 18003792A | IN | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 201201560 | 05 | IN | MEDICAID |