1033146725 NPI number — DR. EVA MAE HENDERSON M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033146725 NPI number — DR. EVA MAE HENDERSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HENDERSON
Provider First Name:
EVA
Provider Middle Name:
MAE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CAMARA
Provider Other First Name:
EVA
Provider Other Middle Name:
HENDERSON
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1033146725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3437
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39207-3437
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-362-5321
Provider Business Mailing Address Fax Number:
601-354-5159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
350 W WOODROW WILSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39213-7681
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-709-5150
Provider Business Practice Location Address Fax Number:
601-709-5151
Provider Enumeration Date:
06/27/2006

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:  10119 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1692743 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00116298 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




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