Provider Demographics
NPI:1417933284
Name:HENDERSON, DAVID J (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:J
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 1:280 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6236
Mailing Address - Country:US
Mailing Address - Phone:801-505-0821
Mailing Address - Fax:
Practice Address - Street 1:440 MEDICAL DR STE 3
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-5174
Practice Address - Country:US
Practice Address - Phone:385-722-9566
Practice Address - Fax:385-722-9567
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1593801205208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1518109032Medicaid
UT05356Medicaid
UT000066112Medicare PIN
P00719436Medicare PIN
UT005701316Medicare ID - Type Unspecified
UT1518109032Medicaid
D20175Medicare UPIN
UT005536811Medicare ID - Type Unspecified