Provider Demographics
NPI:1720247794
Name:MARK S HENDERSON M D P A
Entity type:Organization
Organization Name:MARK S HENDERSON M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:SHEA
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-908-3595
Mailing Address - Street 1:1101 RAINTREE CIR
Mailing Address - Street 2:SUITE 240
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-4922
Mailing Address - Country:US
Mailing Address - Phone:972-908-3595
Mailing Address - Fax:972-908-3596
Practice Address - Street 1:1101 RAINTREE CIR
Practice Address - Street 2:SUITE 240
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-4922
Practice Address - Country:US
Practice Address - Phone:972-908-3595
Practice Address - Fax:972-908-3596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-05
Last Update Date:2010-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ4200208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX113358901Medicaid
TX990010000OtherRAILROAD MEDICARE
TX8BF145OtherBCBS
TX8BF145OtherBCBS
TXG10866Medicare UPIN