Provider Demographics
NPI:1164583084
Name:HENDRICKS, SEAN DAVID (MD)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:DAVID
Last Name:HENDRICKS
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 1:2020 W ILES AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4174
Mailing Address - Country:US
Mailing Address - Phone:217-698-3030
Mailing Address - Fax:217-698-4728
Practice Address - Street 1:2020 W ILES AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4174
Practice Address - Country:US
Practice Address - Phone:217-492-9629
Practice Address - Fax:217-698-4728
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA026330207W00000X
TN42382207W00000X
IL036147214207WX0107X
MS20248207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00226767Medicaid
MS302I182564OtherMEDICARE PTAN