Provider Demographics
NPI:1972562106
Name:HENDERSON, BRUCE T (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:T
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44555 WOODWARD AVE
Mailing Address - Street 2:SUITE 407
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5031
Mailing Address - Country:US
Mailing Address - Phone:248-334-0524
Mailing Address - Fax:248-858-3887
Practice Address - Street 1:44555 WOODWARD AVE
Practice Address - Street 2:SUITE 407
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5031
Practice Address - Country:US
Practice Address - Phone:248-334-0524
Practice Address - Fax:248-858-3887
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI039951174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0638406OtherBLUE CROSS/BLUE SHIELD
MI4513265Medicaid
MI4513265Medicaid