Provider Demographics
NPI:1699804542
Name:HENDERSON, ANITA LOUISE (MD)
Entity type:Individual
Prefix:
First Name:ANITA
Middle Name:LOUISE
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 1:11089 RESORT RD STE 206
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-2073
Mailing Address - Country:US
Mailing Address - Phone:410-696-3605
Mailing Address - Fax:410-696-1387
Practice Address - Street 1:11089 RESORT RD STE 206
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-2073
Practice Address - Country:US
Practice Address - Phone:410-696-3605
Practice Address - Fax:410-696-1387
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD29175207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD030771800Medicaid
C88949Medicare UPIN