Healthcare Provider Details

I. General information

NPI: 1457467375
Provider Name (Legal Business Name): BONNIE B. HUDAK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2006
Last Update Date: 10/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

807 CHILDRENS WAY
JACKSONVILLE FL
32207-8426
US

IV. Provider business mailing address

PO BOX 191 PROVIDER ENROLLMENT DEPT
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 904-390-3788
  • Fax: 904-390-3429
Mailing address:
  • Phone: 302-651-6212
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME69794
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberME69794
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License NumberME69794
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: