Provider Demographics
NPI:1689074957
Name:HENDRICKSON, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:HENDRICKSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 KNICKERBOCKER DR
Mailing Address - Street 2:
Mailing Address - City:BELLE MEAD
Mailing Address - State:NJ
Mailing Address - Zip Code:08502-4545
Mailing Address - Country:US
Mailing Address - Phone:908-255-2087
Mailing Address - Fax:
Practice Address - Street 1:11050 MT BELVEDERE BLVD
Practice Address - Street 2:
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602-2603
Practice Address - Country:US
Practice Address - Phone:908-255-2087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-24
Last Update Date:2025-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X, 390200000X
VA0101282168207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program