Provider Demographics
NPI:1679564835
Name:HUDSON, LARRY DAVID (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DAVID
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 1:1021 W OAKLAND AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2191
Mailing Address - Country:US
Mailing Address - Phone:423-928-9014
Mailing Address - Fax:423-928-3559
Practice Address - Street 1:1021 W OAKLAND AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-2191
Practice Address - Country:US
Practice Address - Phone:423-928-9014
Practice Address - Fax:423-928-9014
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000013019207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0101OtherJOHN DEERE HEALTHCARE
TN3701830Medicaid
0036521OtherBCBS TENNESSEE
TN3701830Medicaid
B04381Medicare UPIN