Basic Information
Provider Information | |||||||||
NPI: | 1568130441 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | GREGORY L HENDERSON MD FACS INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 403 VONDERBURG DR | ||||||||
Address2: |   | ||||||||
City: | BRANDON | ||||||||
State: | FL | ||||||||
PostalCode: | 335115982 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8136811122 | ||||||||
FaxNumber: | 8136844924 | ||||||||
Practice Location | |||||||||
Address1: | 5800 49TH ST. N. | ||||||||
Address2: | STE 5108 | ||||||||
City: | ST. PETERBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 337092146 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7273903937 | ||||||||
FaxNumber: | 7273903940 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/03/2021 | ||||||||
LastUpdateDate: | 09/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
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: | 09/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Ophthalmology |   |
No ID Information.