Healthcare Provider Details

I. General information

NPI: 1912067273
Provider Name (Legal Business Name): CHARLES GERRY HENDERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2006
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 ELLICOTT ST
BUFFALO NY
14203-1021
US

IV. Provider business mailing address

726 EXCHANGE ST STE 710
BUFFALO NY
14210-1464
US

V. Phone/Fax

Practice location:
  • Phone: 716-323-2000
  • Fax:
Mailing address:
  • Phone: 716-852-4772
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberME131967
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number18271
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License NumberG188367
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number18271
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: