Provider Demographics
NPI:1730990722
Name:DAVID J HENDERSON M D A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:DAVID J HENDERSON M D A PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-721-4017
Mailing Address - Street 1:280 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6236
Mailing Address - Country:US
Mailing Address - Phone:801-505-0821
Mailing Address - Fax:801-505-0803
Practice Address - Street 1:440 MEDICAL DR STE 3
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-5174
Practice Address - Country:US
Practice Address - Phone:385-722-9566
Practice Address - Fax:385-722-9567
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVID J HENDERSON M D A PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-01-17
Last Update Date:2025-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty