Provider Demographics
NPI:1427135086
Name:HENDERSON, MICHAEL POTTER (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:POTTER
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:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-446-5888
Mailing Address - Fax:757-446-5918
Practice Address - Street 1:825 FAIRFAX AVE
Practice Address - Street 2:SUITE 710
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1914
Practice Address - Country:US
Practice Address - Phone:757-446-5888
Practice Address - Fax:757-446-5918
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012422522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA413231OtherANTHEM BC/BS
VAPAROtherMANAGED HEALTH NETWORK/TRICARE
VAPAROtherCIGNA BEHAVIORAL HEALTH
VA1427135086Medicaid
VAPAROtherVIRGINIA PREMIER HEALTH PLAN
VAPAROtherUNITED BEHAVIORAL HEALTH
NC5916090Medicaid
VAPAROtherFIRST HEALTH COMMERCIAL/COVENTRY HEALTH
VAPAROtherVALUE OPTIONS
VA600484-052OtherMAGELLAN HEALTH SERVICES
VAPAROtherCORVEL/CORCARE
VAPAROtherMULTIPLAN
VA1427135086OtherOPTIMA BEHAVIORAL HEALTH
VAPAROtherAETNA
VAPAROtherUSA MANAGED CARE
VAPAROtherVIRGINIA HEALTH NETWORK
VAP01288858Medicare PIN
VAVAA103654Medicare PIN