Provider Demographics
NPI:1699328013
Name:HENDERSON, ANDREW (OD)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 N ROBINSON AVE APT 221
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-4916
Mailing Address - Country:US
Mailing Address - Phone:847-337-0642
Mailing Address - Fax:
Practice Address - Street 1:14701 N SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3411
Practice Address - Country:US
Practice Address - Phone:405-752-2733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-24
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3023152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist