Provider Demographics
NPI:1790847994
Name:HUDSON, M'LISS A (MD)
Entity Type:Individual
Prefix:
First Name:M'LISS
Middle Name:A
Last Name:HUDSON
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 847176
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7176
Mailing Address - Country:US
Mailing Address - Phone:903-237-1800
Mailing Address - Fax:903-237-1810
Practice Address - Street 1:802 MEDICAL DR
Practice Address - Street 2:SUITE 400
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5100
Practice Address - Country:US
Practice Address - Phone:903-757-7871
Practice Address - Fax:903-753-2479
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.205535208800000X
MOR8H73208800000X
TXG3482208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX123023705Medicaid
MS02005302Medicaid
LA2307941Medicaid
LA2307941Medicaid
LA247831YH3UMedicare PIN
005010219Medicare PIN
TX372731YKS4Medicare PIN