Provider Demographics
NPI:1174589592
Name:HENDERSON, MICHAEL SENTMAN (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SENTMAN
Last Name:HENDERSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 HARRY KEMP WAY
Mailing Address - Street 2:
Mailing Address - City:PROVINCETOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02657-1618
Mailing Address - Country:US
Mailing Address - Phone:508-432-1400
Mailing Address - Fax:
Practice Address - Street 1:49 HARRY KEMP WAY
Practice Address - Street 2:
Practice Address - City:PROVINCETOWN
Practice Address - State:MA
Practice Address - Zip Code:02657-1618
Practice Address - Country:US
Practice Address - Phone:508-432-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2014-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC879152W00000X
MA4789152W00000X
GA1102152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD08793Medicaid
SCD08793Medicaid
SC0127410001Medicare NSC
T976440282Medicare ID - Type Unspecified