Healthcare Provider Details

I. General information

NPI: 1144219585
Provider Name (Legal Business Name): MICHAEL DAVID HENDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2360 1ST ST
NAPA CA
94559-2239
US

IV. Provider business mailing address

104 MILLIKEN CREEK DR
NAPA CA
94558-1241
US

V. Phone/Fax

Practice location:
  • Phone: 707-377-1007
  • Fax:
Mailing address:
  • Phone: 313-930-0909
  • Fax: 248-203-9110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number4301029337
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: