Provider Demographics
NPI:1366592859
Name:HENDERSON, KIMBERLY J (MD)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:J
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 WARREN ST
Mailing Address - Street 2:#32
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10007-1013
Mailing Address - Country:US
Mailing Address - Phone:917-471-0923
Mailing Address - Fax:
Practice Address - Street 1:1251 STAFFORD ST UNIT 6
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-3349
Practice Address - Country:US
Practice Address - Phone:980-290-5515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-10
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD15533207P00000X
MI4301110971207P00000X
WA60922767207P00000X
IN01077015A207P00000X
UT11085788-1205207P00000X
DCMD043819207P00000X
MEMD20776207P00000X
PAMD466064207P00000X
NJ25MA09842100207P00000X
CT54929207P00000X
MDDO080667207P00000X
NY232889207PE0004X
NC2020-00646207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02574490Medicaid
MEE100258967Medicare PIN
NY02574490Medicaid