MEDICARE: TRAVIS T HENDERSON M.D.

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	2085R0202X	Diagnostic Radiology Physician	2009-00720	NC

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
2	153AM	OTHER	NC	BCBS

General Provider Information

NPI Number	:	1679539381
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRAVIS T HENDERSON M.D.

Provider Business Mailing Address
First Line	:	P O BOX 120590
Second Line	:
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23612-0590
Country	:	US
Telephone Number	:	757-867-6101
Fax Number	:	757-867-6588

Provider Business Practice Location Address
First Line	:	1135 CARTHAGE ST
Second Line	:	CENTRAL CAROLINA RADIOLOGY
City	:	SANFORD
State	:	NC
Zip	:	27330-4162
Country	:	US
Telephone Number	:	919-777-7092
Fax Number	:	919-774-2399

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/21/2006
Last Update Date	:	05/29/2024

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