Provider Demographics
NPI:1851349195
Name:HUDSON, HENRY L (MD)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:L
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 1:5565 GROSSMONT CENTER DR STE 551
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3078
Mailing Address - Country:US
Mailing Address - Phone:800-898-2020
Mailing Address - Fax:505-344-5404
Practice Address - Street 1:5565 GROSSMONT CENTER DR.
Practice Address - Street 2:BLDG3 STE 551
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-9194
Practice Address - Country:US
Practice Address - Phone:800-898-2020
Practice Address - Fax:844-897-3788
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ24189207W00000X
CAG76091207W00000X
NMMD2014-0974207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ343955OtherAHCCCS
NM55109039Medicaid
AZ2629305001OtherCIGNA
AZ629190OtherAETNA
AZAZ0392720OtherBLUE CROSS/ BLUE SHIELD
AZ2629305001OtherCIGNA
AZWMBPNMedicare PIN