Provider Demographics
NPI:1215005087
Name:HUDAK, MARK J (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:J
Last Name:HUDAK
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 1:10963 WOLF AVENUE NE
Mailing Address - Street 2:
Mailing Address - City:HARTVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44632
Mailing Address - Country:US
Mailing Address - Phone:330-877-8498
Mailing Address - Fax:
Practice Address - Street 1:1811 SCHNEIDER ST NE
Practice Address - Street 2:MERCY HEALTH CENTER
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44721-3349
Practice Address - Country:US
Practice Address - Phone:330-588-4884
Practice Address - Fax:330-494-6484
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-063048207Q00000X
OH35063048207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2176925Medicaid
OH2176925Medicaid
OHG75995Medicare UPIN