Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 20470 | WV |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 20470 | WV |
NPI | 1295799963 |
---|---|
Provider Name | James Martin Henderson |
First Address | Charleston, WV 25301-1842 |
Second Address | Charleston, WV 25301-1842 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/04/2006 |
Last Update Date | 09/06/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
4002055-000 | (05) | WV |
4002055001 | (05) | WV |
850000287 | RAILROAD MEDICARE (01) | |
H41479 | (02) |