Healthcare Provider Details

I. General information

NPI: 1588648208
Provider Name (Legal Business Name): ANITA RUTH HENDERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 NW KINGWOOD AVE SUITE B
REDMOND OR
97756-1324
US

IV. Provider business mailing address

1925 NW 2ND ST
BEND OR
97703-1249
US

V. Phone/Fax

Practice location:
  • Phone: 541-548-7134
  • Fax: 541-278-8350
Mailing address:
  • Phone: 541-977-7754
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC54649
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD27129
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: