Provider Demographics
NPI:1487911012
Name:HENDRICKS, TRAVIS LAMONT (DO)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:LAMONT
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 FAIRWAY CT APT L
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-7255
Mailing Address - Country:US
Mailing Address - Phone:305-951-5523
Mailing Address - Fax:587-487-6166
Practice Address - Street 1:9 HOSPITAL DR STE B4
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-6425
Practice Address - Country:US
Practice Address - Phone:732-905-6635
Practice Address - Fax:732-905-6643
Is Sole Proprietor?:No
Enumeration Date:2012-04-20
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT014442390200000X
NJ25MB10117100207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program