Healthcare Provider Details

I. General information

NPI: 1659492627
Provider Name (Legal Business Name): JOHNNY (BLAINE) HENDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 12/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N BEAVER ST
FLAGSTAFF AZ
86001-3118
US

IV. Provider business mailing address

1200 N BEAVER ST PAYER CREDENTIALING
FLAGSTAFF AZ
86001-3118
US

V. Phone/Fax

Practice location:
  • Phone: 928-213-6415
  • Fax: 928-213-6409
Mailing address:
  • Phone: 928-773-2559
  • Fax: 928-213-6292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number48599
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: