Provider Demographics
NPI:1558590703
Name:HUDSON, MANDILIN GORDON (DO)
Entity Type:Individual
Prefix:
First Name:MANDILIN
Middle Name:GORDON
Last Name:HUDSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3509 NW SAMARITAN DR
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-3893
Mailing Address - Country:US
Mailing Address - Phone:541-768-5235
Mailing Address - Fax:
Practice Address - Street 1:3509 NW SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-3893
Practice Address - Country:US
Practice Address - Phone:541-768-5235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDO1547132084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry