=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750185583
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMY MICHAEL HUDAK
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/02/2025
-----------------------------------------------------
Last Update Date | 01/22/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12975 COLLIER BLVD STE A102
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34116-4004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-300-4779
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12975 COLLIER BLVD STE A102
-----------------------------------------------------
City | NAPLES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34116-4004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-615-3140
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT44299
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT03971
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------