Healthcare Provider Details

I. General information

NPI: 1417927468
Provider Name (Legal Business Name): ROBERT HENDERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1705 W 2ND ST
ELK CITY OK
73644-4455
US

IV. Provider business mailing address

PO BOX 47686
WICHITA KS
67201-7686
US

V. Phone/Fax

Practice location:
  • Phone: 580-225-2511
  • Fax:
Mailing address:
  • Phone: 316-685-6236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number16816
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: