Provider Demographics
NPI:1700863438
Name:HUDSON, JOHN KENNISON (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KENNISON
Last Name:HUDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:3696 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6520
Mailing Address - Country:US
Mailing Address - Phone:706-736-1830
Mailing Address - Fax:706-737-5103
Practice Address - Street 1:3696 WHEELER RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6520
Practice Address - Country:US
Practice Address - Phone:706-736-1830
Practice Address - Fax:706-737-5103
Is Sole Proprietor?:No
Enumeration Date:2005-12-23
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041582174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA3600044OtherUNITED HEALTHCARE
GA00723874Medicaid
SCG41582Medicaid
GA2126300OtherAETNA
GAP00035369OtherRAILROAD MEDICARE
GA717228OtherBLUE CROSS BLUE SHIELD
GAP00035369OtherRAILROAD MEDICARE
GA3600044OtherUNITED HEALTHCARE