Healthcare Provider Details

I. General information

NPI: 1790963759
Provider Name (Legal Business Name): JOSEPH BERNARD HENDERSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 08/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 VALLEYGATE DR
FAYETTEVILLE NC
28304-3745
US

IV. Provider business mailing address

PO BOX 87112
FAYETTEVILLE NC
28304-7112
US

V. Phone/Fax

Practice location:
  • Phone: 910-323-5203
  • Fax: 910-323-3650
Mailing address:
  • Phone: 412-527-8518
  • Fax: 910-323-3650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2013-00623
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: