Healthcare Provider Details

I. General information

NPI: 1710163050
Provider Name (Legal Business Name): TODD MARCOS HENDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 SOUTHCREST CIR STE 201
SOUTHAVEN MS
38671-4737
US

IV. Provider business mailing address

965 RIDGE LAKE BLVD STE 315
MEMPHIS TN
38120-9401
US

V. Phone/Fax

Practice location:
  • Phone: 662-349-0488
  • Fax: 662-349-5974
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberE-12098
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number48203
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberE-12098
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number22431
License Number StateMS
# 5
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number48203
License Number StateTN
# 6
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberE-12098
License Number StateAR
# 7
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number48203
License Number StateTN
# 8
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number22431
License Number StateMS
# 9
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number22431
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: