Provider Demographics
NPI:1215976022
Name:HENDERSON, LARRY A JR (MD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:A
Last Name:HENDERSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1007
Mailing Address - Street 2:
Mailing Address - City:LUCEDALE
Mailing Address - State:MS
Mailing Address - Zip Code:39452-1007
Mailing Address - Country:US
Mailing Address - Phone:601-947-8181
Mailing Address - Fax:601-947-4411
Practice Address - Street 1:92 RATLIFF ST
Practice Address - Street 2:
Practice Address - City:LUCEDALE
Practice Address - State:MS
Practice Address - Zip Code:39452-6537
Practice Address - Country:US
Practice Address - Phone:601-947-8181
Practice Address - Fax:601-947-4411
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2018-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19697207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009966685Medicaid
FL270736500Medicaid
AL01-01886OtherUNITED HEALTH CARE
MS09435313Medicaid
MSP00696992OtherPALMETTO GBA
AL51523926OtherBLUE CROSS
LA1502324Medicaid
FL270736500Medicaid
MS09435313Medicaid