Basic Information
Provider Information | |||||||||
NPI: | 1518166354 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HENDERSON | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | DWAYNE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2 SAINT MARKS PL STE 160 | ||||||||
Address2: |   | ||||||||
City: | LA GRANGE | ||||||||
State: | TX | ||||||||
PostalCode: | 789451253 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9792425677 | ||||||||
FaxNumber: | 9792425680 | ||||||||
Practice Location | |||||||||
Address1: | 1900 SCENIC DR | ||||||||
Address2: | SUITE 3308 | ||||||||
City: | GEORGETOWN | ||||||||
State: | TX | ||||||||
PostalCode: | 786267724 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5128692566 | ||||||||
FaxNumber: | 5128697434 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2007 | ||||||||
LastUpdateDate: | 02/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Q9636 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.