Healthcare Provider Details

I. General information

NPI: 1801844931
Provider Name (Legal Business Name): KEITH HENDERSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1638 OWEN DR
FAYETTEVILLE NC
28304-3424
US

IV. Provider business mailing address

1638 OWEN DRIVE ATTN: MANAGED CARE PLANNING
FAYETTEVILLE NC
28304
US

V. Phone/Fax

Practice location:
  • Phone: 910-609-4592
  • Fax: 910-609-5179
Mailing address:
  • Phone: 910-615-6949
  • Fax: 910-615-9761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9400073
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number9400073
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: