Provider Demographics
NPI:1679539381
Name:HENDERSON, TRAVIS T (MD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:T
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:P O BOX 120590
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23612-0590
Mailing Address - Country:US
Mailing Address - Phone:757-867-6101
Mailing Address - Fax:757-867-6588
Practice Address - Street 1:1135 CARTHAGE ST
Practice Address - Street 2:CENTRAL CAROLINA RADIOLOGY
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-4162
Practice Address - Country:US
Practice Address - Phone:919-777-7092
Practice Address - Fax:919-774-2399
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-007202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5911860Medicaid
NC153AMOtherBCBS
NC5911860Medicaid