Provider Demographics
NPI:1902883762
Name:HENDERSON, MARK H JR (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:H
Last Name:HENDERSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:23000 MOAKLEY ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:LEONARDTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20650-2915
Mailing Address - Country:US
Mailing Address - Phone:301-475-5555
Mailing Address - Fax:301-475-8535
Practice Address - Street 1:23000 MOAKLEY ST
Practice Address - Street 2:SUITE 102
Practice Address - City:LEONARDTOWN
Practice Address - State:MD
Practice Address - Zip Code:20650-2915
Practice Address - Country:US
Practice Address - Phone:301-475-5555
Practice Address - Fax:301-475-8535
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MDD0040288207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDH490Y523Medicare ID - Type Unspecified
MDE66174Medicare UPIN