Healthcare Provider Details

I. General information

NPI: 1487649000
Provider Name (Legal Business Name): JUSTIN R HUDSON DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 11/08/2023
Certification Date: 11/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 W WILSON BRIDGE RD STE 200
WORTHINGTON OH
43085-2591
US

IV. Provider business mailing address

6480 HARRISON AVE STE 201
CINCINNATI OH
45247-7961
US

V. Phone/Fax

Practice location:
  • Phone: 614-895-8747
  • Fax: 614-895-8810
Mailing address:
  • Phone: 513-713-1779
  • Fax: 138-549-9215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number07000948A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36.003706
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: