Healthcare Provider Details

I. General information

NPI: 1063404788
Provider Name (Legal Business Name): FRASER HENDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 MERCANTILE LN STE 341
UPPER MARLBORO MD
20774-4331
US

IV. Provider business mailing address

1401 MERCANTILE LN
UPPER MARLBORO MD
20774-4301
US

V. Phone/Fax

Practice location:
  • Phone: 301-557-9049
  • Fax: 301-654-9394
Mailing address:
  • Phone: 301-557-9049
  • Fax: 301-654-9394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number20803
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: