Provider Demographics
NPI:1285773960
Name:MARK G HENDSERSON MD PC
Entity type:Organization
Organization Name:MARK G HENDSERSON MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-735-0077
Mailing Address - Street 1:2575 S CIMARRON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117
Mailing Address - Country:US
Mailing Address - Phone:702-735-0077
Mailing Address - Fax:702-866-0077
Practice Address - Street 1:2575 S CIMARRON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117
Practice Address - Country:US
Practice Address - Phone:702-735-0077
Practice Address - Fax:702-866-0077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6058207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVMD6058Medicare ID - Type Unspecified
E81411Medicare UPIN