Healthcare Provider Details

I. General information

NPI: 1710995295
Provider Name (Legal Business Name): REUBEN GUY HUDSON MD FAAP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E JEFFERSON ST
BOISE ID
83712-6231
US

IV. Provider business mailing address

190 E BANNOCK ST
BOISE ID
83712-6241
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-6196
  • Fax: 208-381-6199
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number7161277
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD25800
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberMD00048852
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: