Provider Demographics
NPI:1679540090
Name:HENDERSON, JOSEPH MARVIN (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MARVIN
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N RITTER AVE
Practice Address - Street 2:STE 370
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219
Practice Address - Country:US
Practice Address - Phone:317-355-1144
Practice Address - Fax:317-355-1155
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01042307A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000793527OtherANTHEM
INP01170017OtherRR MEDICARE PTAN
IN100474160AMedicaid
C78310Medicare UPIN
IN266180049Medicare PIN
INP01170017OtherRR MEDICARE PTAN