Healthcare Provider Details

I. General information

NPI: 1679539381
Provider Name (Legal Business Name): TRAVIS T HENDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 05/29/2024
Certification Date: 05/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 CARTHAGE ST CENTRAL CAROLINA RADIOLOGY
SANFORD NC
27330-4162
US

IV. Provider business mailing address

P O BOX 120590
NEWPORT NEWS VA
23612-0590
US

V. Phone/Fax

Practice location:
  • Phone: 919-777-7092
  • Fax: 919-774-2399
Mailing address:
  • Phone: 757-867-6101
  • Fax: 757-867-6588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2009-00720
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: