Healthcare Provider Details

I. General information

NPI: 1558987099
Provider Name (Legal Business Name): MICHAEL JOHN HUDOCK JR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2020
Last Update Date: 09/19/2026
Certification Date: 09/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 N MEDICAL DR
SALT LAKE CITY UT
84112-1100
US

IV. Provider business mailing address

85 N MEDICAL DR
SALT LAKE CITY UT
84112-1100
US

V. Phone/Fax

Practice location:
  • Phone: 801-581-7985
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P0010X
TaxonomyPediatric Rehabilitation Medicine Physician
License Number14297943-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: