Provider Demographics
NPI:1902906084
Name:HENDERSON, PETER L JR (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:L
Last Name:HENDERSON
Suffix:JR
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:PO BOX 12938
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:GA
Mailing Address - Zip Code:30703-7013
Mailing Address - Country:US
Mailing Address - Phone:706-602-7800
Mailing Address - Fax:706-879-5843
Practice Address - Street 1:106 HOSPITAL DR
Practice Address - Street 2:SUITE 6
Practice Address - City:CHATSWORTH
Practice Address - State:GA
Practice Address - Zip Code:30705-2070
Practice Address - Country:US
Practice Address - Phone:706-695-9240
Practice Address - Fax:706-695-9241
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2016-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA27386208600000X
NC2010-00324208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP4720OtherGROUP #
GA666324OtherWELLCARE
GA202I022543Medicare UPIN
GA300003537AMedicaid
GA300003537BMedicaid
NCD40111Medicare UPIN
GA000299285EMedicaid
GA52235354OtherBCBS
GA300003537CMedicaid
GA300003537DMedicaid