Healthcare Provider Details

I. General information

NPI: 1215976022
Provider Name (Legal Business Name): LARRY A HENDERSON JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 12/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 RATLIFF ST
LUCEDALE MS
39452-6537
US

IV. Provider business mailing address

PO BOX 1007
LUCEDALE MS
39452-1007
US

V. Phone/Fax

Practice location:
  • Phone: 601-947-8181
  • Fax: 601-947-4411
Mailing address:
  • Phone: 601-947-8181
  • Fax: 601-947-4411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number19697
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: