Raven Henderson, M.D.

Primary specialty

Plastic Surgery PhysicianTaxonomy code 208200000X

License

04-40363 Issued in KS

Practice address

2140 W Grande Blvd Ste a
Tyler, TX 75703-0563

Phone

(903) 251-2765

Fax

(270) 216-6827

NPI assigned

Apr 11, 2012

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Jan 23, 2025 through Jan 23, 2027

Medicare enrollment (NPD)

Not enrolled

HHS exclusion list flag

Flagged The directory lists this NPI on an HHS exclusion list. The OIG exclusions file (LEIE) holds no record for this NPI, and the directory does not say which list the flag comes from. How exclusions are shown Confirm with the OIG exclusions search.

Credentials

Doctor of Medicine

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1334102400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1720137600000",
    "number": "1437415726",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2140 W GRANDE BLVD STE A",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757030563",
            "telephone_number": "903-251-2765",
            "fax_number": "270-216-6827"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2140 W GRANDE BLVD STE A",
            "city": "TYLER",
            "state": "TX",
            "postal_code": "757030563",
            "telephone_number": "903-251-2765",
            "fax_number": "270-216-6827"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "HENDERSON",
        "first_name": "RAVEN",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2012-04-11",
        "last_updated": "2024-07-05",
        "certification_date": "2024-07-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208200000X",
            "taxonomy_group": "",
            "desc": "Plastic Surgery",
            "state": "KS",
            "license": "04-40363",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Debra Henderson, LPC
• Dorinda Henderson, LBSW
• Gina R Henderson
• Hattie E Henderson, M.D.
• Heather L Henderson
• Rebecca Henderson, MA, LPC
• Tyra Henderson
• Hendricks Chiropractic, P.a.
• Craig B. Hendricks, D.C.
• Michael Bret Hendricks, MD

• Plastic Surgery Physician in Tyler, TX
• Providers in Tyler, TX by specialty
• Plastic Surgery Physician in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 5, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.