Provider Demographics
NPI:1528147550
Name:HENDERSON, LINDA REED (MD)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:REED
Last Name:HENDERSON
Suffix:
Gender:F
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 1005
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93265-1005
Mailing Address - Country:US
Mailing Address - Phone:559-539-3684
Mailing Address - Fax:661-397-4213
Practice Address - Street 1:3004 BELHAVEN ST
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93304-5509
Practice Address - Country:US
Practice Address - Phone:559-539-3684
Practice Address - Fax:661-397-4213
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23340208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G233400Medicaid
CACMS068720OtherCCS
A89379Medicare UPIN
CA00G233401Medicare ID - Type Unspecified