Healthcare Provider Details

I. General information

NPI: 1710506530
Provider Name (Legal Business Name): MICHELE DEMUTH HENDERSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELE KRISTEN DEMUTH

II. Dates (important events)

Enumeration Date: 04/12/2020
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 PHEASANT RUN
NEWTOWN PA
18940-3439
US

IV. Provider business mailing address

104 PHEASANT RUN
NEWTOWN PA
18940-3439
US

V. Phone/Fax

Practice location:
  • Phone: 215-968-6844
  • Fax:
Mailing address:
  • Phone: 215-968-6844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD480970
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: