Provider Demographics
NPI:1932434891
Name:GREGORY L HENDERSON MD FACS INC
Entity type:Organization
Organization Name:GREGORY L HENDERSON MD FACS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:MD
Authorized Official - Phone:813-681-1122
Mailing Address - Street 1:403 VONDERBURG DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5982
Mailing Address - Country:US
Mailing Address - Phone:813-681-1122
Mailing Address - Fax:813-684-4924
Practice Address - Street 1:711 S HOWARD AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-2465
Practice Address - Country:US
Practice Address - Phone:813-708-5270
Practice Address - Fax:813-253-0933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC2224152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty