Provider Demographics
NPI:1902878218
Name:HUDSON, DEIDRE J (MD)
Entity Type:Individual
Prefix:
First Name:DEIDRE
Middle Name:J
Last Name:HUDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEIDRE
Other - Middle Name:J
Other - Last Name:HUDSON-STANTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:201 BUSINESS CENTER DR
Mailing Address - Street 2:
Mailing Address - City:PAWLEYS ISLAND
Mailing Address - State:SC
Mailing Address - Zip Code:29585-6522
Mailing Address - Country:US
Mailing Address - Phone:888-467-1117
Mailing Address - Fax:888-990-3903
Practice Address - Street 1:201 BUSINESS CENTER DR
Practice Address - Street 2:
Practice Address - City:PAWLEYS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29585-6522
Practice Address - Country:US
Practice Address - Phone:888-467-1117
Practice Address - Fax:888-990-3903
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19084207Q00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC190849Medicaid
SCH01099Medicare UPIN
SCH010995772Medicare PIN