Basic Information
| Provider Information | |||||||||
| NPI: | 1699848325 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HENSON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 N CLYDE MORRIS BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321142709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862264590 | ||||||||
| FaxNumber: | 3862263371 | ||||||||
| Practice Location | |||||||||
| Address1: | 775 W. GRANDA BLVD | ||||||||
| Address2: | |||||||||
| City: | ORMOND BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321745109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864254480 | ||||||||
| FaxNumber: | 3864257511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2006 | ||||||||
| LastUpdateDate: | 01/09/2017 | ||||||||
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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 | 207P00000X | ME0025744 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | ME25744 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | ME0025744 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | ME25744 | 01 | FL | STATE MEDICAL LICENSE | OTHER | 059887900 | 05 | FL | MEDICAID |