Provider Demographics
NPI:1063527968
Name:HENDERSON, ROY ROBERT (DPM)
Entity type:Individual
Prefix:DR
First Name:ROY
Middle Name:ROBERT
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 WEST UNION AVE
Mailing Address - Street 2:
Mailing Address - City:BOUND BROOK
Mailing Address - State:NJ
Mailing Address - Zip Code:08805-1716
Mailing Address - Country:US
Mailing Address - Phone:732-469-3668
Mailing Address - Fax:732-469-3650
Practice Address - Street 1:60 WEST UNION AVE
Practice Address - Street 2:
Practice Address - City:BOUND BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08805-1716
Practice Address - Country:US
Practice Address - Phone:732-469-3668
Practice Address - Fax:732-469-3650
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00176300213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJF08076OtherHEALTH NET
NJ1838709Medicaid
NJP384246OtherOXFORD
T45417Medicare UPIN
NJ1838709Medicaid
NJ1071750001Medicare NSC