Provider Demographics
NPI:1790839983
Name:HUDSON, THERESA MARJORIE (MD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:MARJORIE
Last Name:HUDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:THERESA
Other - Middle Name:PERRY
Other - Last Name:HUDSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2700 HIGHWAY 34 E
Mailing Address - Street 2:BLDG 300
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-2315
Mailing Address - Country:US
Mailing Address - Phone:770-304-0987
Mailing Address - Fax:770-251-0938
Practice Address - Street 1:2700 HIGHWAY 34 E
Practice Address - Street 2:BLDG 300
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-2315
Practice Address - Country:US
Practice Address - Phone:770-304-0987
Practice Address - Fax:770-251-0938
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039594207Q00000X
CA147556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000708045CMedicaid
GAG06867Medicare UPIN
GA000708045CMedicaid