Basic Information
| Provider Information | |||||||||
| NPI: | 1326080045 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENSON | ||||||||
| FirstName: | ELLIOT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 GRAND STREET | ||||||||
| Address2: | 3RD FL | ||||||||
| City: | WARWICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109901035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453540011 | ||||||||
| FaxNumber: | 8459875979 | ||||||||
| Practice Location | |||||||||
| Address1: | 26 FIREMANS MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109703553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453540011 | ||||||||
| FaxNumber: | 8453540147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2006 | ||||||||
| LastUpdateDate: | 11/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 136678 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00933913 | 05 | NY | MEDICAID |