Healthcare Provider Details

I. General information

NPI: 1164119525
Provider Name (Legal Business Name): MATTHEW HENDERSON DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

V. Phone/Fax

Practice location:
  • Phone: 701-433-0037
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number0102208748
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: