Provider Demographics
NPI:1457467375
Name:HUDAK, BONNIE B (MD)
Entity Type:Individual
Prefix:DR
First Name:BONNIE
Middle Name:B
Last Name:HUDAK
Suffix:
Gender:F
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 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-6212
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:807 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8426
Practice Address - Country:US
Practice Address - Phone:904-390-3788
Practice Address - Fax:904-390-3429
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME69794208000000X, 2080N0001X, 2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000693514AMedicaid
FL379239100Medicaid
GA000693514AMedicaid
FL379239100Medicaid