Healthcare Provider Details

I. General information

NPI: 1780646745
Provider Name (Legal Business Name): DIANE CAROLYN HUDSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 08/21/2020
Certification Date: 08/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5520 STEWART ST
MILTON FL
32570-4304
US

IV. Provider business mailing address

2315 W JACKSON ST
PENSACOLA FL
32505-7552
US

V. Phone/Fax

Practice location:
  • Phone: 850-981-9433
  • Fax: 850-981-9436
Mailing address:
  • Phone: 850-436-4630
  • Fax: 850-436-2095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME93283
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: