Provider Demographics
NPI:1366523110
Name:HENDERSON, STEPHEN BROWN (MD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:BROWN
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 HOMER CLAYTON DR
Mailing Address - Street 2:
Mailing Address - City:GUNTERSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35976-2206
Mailing Address - Country:US
Mailing Address - Phone:256-582-2581
Mailing Address - Fax:256-582-7799
Practice Address - Street 1:2308 HOMER CLAYTON DR
Practice Address - Street 2:
Practice Address - City:GUNTERSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35976-2206
Practice Address - Country:US
Practice Address - Phone:256-582-2581
Practice Address - Fax:256-582-7799
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9278207Q00000X, 207QG0300X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL144869Medicaid
AL144705Medicaid
AL144869Medicaid
AL144705Medicaid