Provider Demographics
NPI:1902804560
Name:HENDERSON, DAVID EUGENE (DPM)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:EUGENE
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CARPET ALY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:IN
Mailing Address - Zip Code:47250-3562
Mailing Address - Country:US
Mailing Address - Phone:812-265-2011
Mailing Address - Fax:812-273-1769
Practice Address - Street 1:1 CARPET ALLEY
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250
Practice Address - Country:US
Practice Address - Phone:812-265-2011
Practice Address - Fax:812-273-1769
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2017-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000436A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100148890AMedicaid
IN257980AOtherMEDICARE DME
35-1787467OtherTAX ID
000000087922OtherANTHEM BCBS
IN411730OtherMEDICARE DME
T35021Medicare UPIN