Provider Demographics
NPI:1215323837
Name:HENDERSON, MATHEW (DO)
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 DENNISTON AVE SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24015-2023
Mailing Address - Country:US
Mailing Address - Phone:540-613-8565
Mailing Address - Fax:
Practice Address - Street 1:1901 DENNISTON AVE SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24015-2023
Practice Address - Country:US
Practice Address - Phone:540-613-8565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102205248208000000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics