Provider Demographics
NPI:1063404788
Name:HENDERSON, FRASER
Entity type:Individual
Prefix:
First Name:FRASER
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 WAYNE AVE STE 420
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-5655
Mailing Address - Country:US
Mailing Address - Phone:301-557-9049
Mailing Address - Fax:
Practice Address - Street 1:8401 CONNECTICUT AVENUE NW
Practice Address - Street 2:
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20814
Practice Address - Country:US
Practice Address - Phone:301-654-9390
Practice Address - Fax:301-654-4919
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC20803207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D17649Medicare UPIN
000S69G65Medicare PIN