Provider Demographics
NPI:1538734348
Name:HENDERSON, STEVEN (OD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12392 OLIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:CREVE COEUR
Mailing Address - State:MO
Mailing Address - Zip Code:63141-6443
Mailing Address - Country:US
Mailing Address - Phone:314-878-8770
Mailing Address - Fax:314-878-5971
Practice Address - Street 1:12392 OLIVE BLVD
Practice Address - Street 2:
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6443
Practice Address - Country:US
Practice Address - Phone:314-878-8770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021020899152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist