Provider Demographics
NPI:1043417421
Name:HUDSON, OMAR DEAN (MD)
Entity Type:Individual
Prefix:DR
First Name:OMAR
Middle Name:DEAN
Last Name:HUDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-723-0072
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1223 GATEWAY DR STE 1G
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-723-0072
Practice Address - Fax:321-952-0850
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME103869208000000X, 2080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9796123OtherAETNA
FLCQ236YOtherMEDICARE
FL000990300Medicaid
FL29192OtherBCBS