Basic Information
| Provider Information | |||||||||
| NPI: | 1790963759 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENDERSON | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | BERNARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 87112 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283047112 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4125278518 | ||||||||
| FaxNumber: | 9103233650 | ||||||||
| Practice Location | |||||||||
| Address1: | 2041 VALLEYGATE DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103235203 | ||||||||
| FaxNumber: | 9103233650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2008 | ||||||||
| LastUpdateDate: | 08/20/2013 | ||||||||
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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 | 207RG0100X | 2013-00623 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 2013-00623 | 01 | NC | LICENSE # | OTHER | 17953 | 01 | BCBS | OTHER |