Provider Demographics
NPI:1861426694
Name:HENDERSON, ROY (MD)
Entity type:Individual
Prefix:
First Name:ROY
Middle Name:
Last Name:HENDERSON
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:PO BOX 869
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46061-0869
Mailing Address - Country:US
Mailing Address - Phone:317-770-6900
Mailing Address - Fax:317-770-6911
Practice Address - Street 1:14535A HAZEL DELL PKWY
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46033-9401
Practice Address - Country:US
Practice Address - Phone:317-705-4360
Practice Address - Fax:317-705-4361
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-104711207Q00000X
IN01075456A207Q00000X, 207QS0010X
IL036104711207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036104711Medicaid
IN201291730Medicaid
IL390361015Medicare PIN
E57863Medicare UPIN
ILL86298Medicare PIN
IN068010151Medicare PIN
IL036104711Medicaid
ININ1546009Medicare PIN
IL0727500001Medicare NSC