Provider Demographics
NPI:1952348070
Name:HENDERSON, LISA L (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:L
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 1:18100 OAKWOOD BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4071
Mailing Address - Country:US
Mailing Address - Phone:313-253-2000
Mailing Address - Fax:
Practice Address - Street 1:2006 HOGBACK RD STE 5A
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-9750
Practice Address - Country:US
Practice Address - Phone:734-263-2417
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061318207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4823320-10Medicaid
MI7050340OtherAETNA
MI4823320-10Medicaid
MIG85763Medicare UPIN