Provider Demographics
NPI:1427055227
Name:HENDERSON, GREGORY L SR (MD)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:L
Last Name:HENDERSON
Suffix:SR
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 1:403 VONDERBURG DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5982
Mailing Address - Country:US
Mailing Address - Phone:813-681-1122
Mailing Address - Fax:813-684-4924
Practice Address - Street 1:403 VONDERBURG DR
Practice Address - Street 2:STE 101
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5982
Practice Address - Country:US
Practice Address - Phone:813-681-1122
Practice Address - Fax:813-684-4924
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0026952207W00000X
FLME26952207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0059735OtherGHI
FL2074202OtherAETNA
FL065634800Medicaid
FL0805213OtherUNITED HEALTHCARE
FL53493OtherBCBS FLORIDA
FL4092871OtherAETNA
FLD56548Medicare UPIN
FL065634800Medicaid
FL53493Medicare PIN
GA180034719Medicare PIN