1295776821 NPI number — KYLE HENDERSON MD

Table of content: KYLE HENDERSON MD (NPI 1295776821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295776821 NPI number — KYLE HENDERSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
KYLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295776821
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3068
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRYAN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77805-3068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
979-696-4440
Provider Business Mailing Address Fax Number:
979-694-8500

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1602 ROCK PRAIRIE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLLEGE STATION
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77845-8306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
979-696-4440
Provider Business Practice Location Address Fax Number:
979-694-8500
Provider Enumeration Date:
06/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  H8121 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 111955404 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com