Provider Demographics
NPI:1154313831
Name:HUDSON, JERRY (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
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:PO BOX 54930
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70154-4930
Mailing Address - Country:US
Mailing Address - Phone:985-785-2221
Mailing Address - Fax:985-785-1118
Practice Address - Street 1:1001 GAUSE BLVD
Practice Address - Street 2:
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2939
Practice Address - Country:US
Practice Address - Phone:985-649-8802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL018487207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1983268Medicaid
LA51893Medicare ID - Type Unspecified
LA1983268Medicaid