Healthcare Provider Details

I. General information

NPI: 1306830799
Provider Name (Legal Business Name): GREGORY L HENDERSON MD FACS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 09/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 N TAMIAMI TRL
RUSKIN FL
33570-3769
US

IV. Provider business mailing address

403 VONDERBURG DR
BRANDON FL
33511-5982
US

V. Phone/Fax

Practice location:
  • Phone: 813-645-3831
  • Fax: 813-645-4402
Mailing address:
  • Phone: 813-681-1122
  • Fax: 813-684-4924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. GREGORY L HENDERSON SR.
Title or Position: PRESIDENT
Credential: MD
Phone: 813-681-1122