Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 25MD00176300 | NJ |
Y | 222Z00000X | Podiatrist | 25MD00176300 | NJ |
NPI | 1063527968 |
---|---|
Provider Name | Dr. Roy Robert Henderson |
First Address | Bound Brook, NJ 08805-1716 |
Second Address | Bound Brook, NJ 08805-1716 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/08/2006 |
Last Update Date | 25/03/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1838709 | (05) | NJ |
F08076 | HEALTH NET (01) | NJ |
P384246 | OXFORD (01) | NJ |
T45417 | (02) |