MEDICARE: GREGORY L HENDERSON MD FACS INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician
2	152W00000X	Optometrist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1306830799
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREGORY L HENDERSON MD FACS INC

Provider Business Mailing Address
First Line	:	403 VONDERBURG DR
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-5982
Country	:	US
Telephone Number	:	813-681-1122
Fax Number	:	813-684-4924

Provider Business Practice Location Address
First Line	:	612 N TAMIAMI TRL
Second Line	:
City	:	RUSKIN
State	:	FL
Zip	:	33570-3769
Country	:	US
Telephone Number	:	813-645-3831
Fax Number	:	813-645-4402

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. GREGORY L HENDERSON SR.
Credential	:	MD
Telephone Number	:	813-681-1122

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	09/19/2017

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