Healthcare Provider Details

I. General information

NPI: 1578624573
Provider Name (Legal Business Name): DONALD WADE HENDERSON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2709 S KOKE MILL RD
SPRINGFIELD IL
62711
US

IV. Provider business mailing address

2709 S KOKE MILL RD
SPRINGFIELD IL
62711-8194
US

V. Phone/Fax

Practice location:
  • Phone: 217-698-9477
  • Fax: 217-698-9474
Mailing address:
  • Phone: 217-698-9477
  • Fax: 217-698-9474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046-009151
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: