Provider Demographics
NPI:1972539773
Name:HENDERSON, MARY SUSAN (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SUSAN
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 1:2729 S HIGHWAY 65 82
Mailing Address - Street 2:
Mailing Address - City:LAKE VILLAGE
Mailing Address - State:AR
Mailing Address - Zip Code:71653-6136
Mailing Address - Country:US
Mailing Address - Phone:870-265-9380
Mailing Address - Fax:870-265-9389
Practice Address - Street 1:2729 S HIGHWAY 65 82
Practice Address - Street 2:
Practice Address - City:LAKE VILLAGE
Practice Address - State:AR
Practice Address - Zip Code:71653-6136
Practice Address - Country:US
Practice Address - Phone:870-265-9380
Practice Address - Fax:870-265-9389
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4988207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1381659Medicaid
LAE75057Medicare UPIN
LA5N437Medicare ID - Type Unspecified