Healthcare Provider Details

I. General information

NPI: 1619109519
Provider Name (Legal Business Name): GREGORY PHILIP HENDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2009
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1441 AVOCADO AVE STE 409
NEWPORT BEACH CA
92660-7705
US

IV. Provider business mailing address

1441 AVOCADO AVE STE 409
NEWPORT BEACH CA
92660-7705
US

V. Phone/Fax

Practice location:
  • Phone: 949-640-4501
  • Fax:
Mailing address:
  • Phone: 949-640-4501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA125261
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA125261
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: