Provider Demographics
NPI:1225026222
Name:HENDERSON, CHRYSTAL DILWORTH (MD)
Entity type:Individual
Prefix:DR
First Name:CHRYSTAL
Middle Name:DILWORTH
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 W LOSEY ST
Mailing Address - Street 2:
Mailing Address - City:SCOTT AIR FORCE BASE
Mailing Address - State:IL
Mailing Address - Zip Code:62225-5250
Mailing Address - Country:US
Mailing Address - Phone:618-256-7456
Mailing Address - Fax:
Practice Address - Street 1:310 W LOSEY ST
Practice Address - Street 2:
Practice Address - City:SCOTT AIR FORCE BASE
Practice Address - State:IL
Practice Address - Zip Code:62225-5250
Practice Address - Country:US
Practice Address - Phone:618-256-7456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN32005171000000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider