Healthcare Provider Details

I. General information

NPI: 1164583084
Provider Name (Legal Business Name): SEAN DAVID HENDRICKS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 W ILES AVE
SPRINGFIELD IL
62704-4174
US

IV. Provider business mailing address

2020 W ILES AVE
SPRINGFIELD IL
62704-4174
US

V. Phone/Fax

Practice location:
  • Phone: 217-492-9629
  • Fax: 217-698-4728
Mailing address:
  • Phone: 217-698-3030
  • Fax: 217-698-4728

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number026330
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number42382
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number20248
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number026330
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: