Provider Demographics
NPI:1184782112
Name:HENSON, BRIAN D (OD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:D
Last Name:HENSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-2170
Mailing Address - Country:US
Mailing Address - Phone:309-693-9540
Mailing Address - Fax:309-693-9754
Practice Address - Street 1:1712 W REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:IL
Practice Address - Zip Code:61764-9695
Practice Address - Country:US
Practice Address - Phone:815-419-2019
Practice Address - Fax:815-419-2021
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-007747152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU05387Medicare UPIN
IL579270042Medicare PIN