Provider Demographics
NPI:1912560202
Name:HUDSON, SAMUEL DAVID (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
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 1:137 STATE ROUTE 3117
Mailing Address - Street 2:
Mailing Address - City:SOUTH SHORE
Mailing Address - State:KY
Mailing Address - Zip Code:41175-9597
Mailing Address - Country:US
Mailing Address - Phone:606-932-2079
Mailing Address - Fax:606-932-2313
Practice Address - Street 1:137 STATE ROUTE 3117
Practice Address - Street 2:
Practice Address - City:SOUTH SHORE
Practice Address - State:KY
Practice Address - Zip Code:41175-9597
Practice Address - Country:US
Practice Address - Phone:606-932-2079
Practice Address - Fax:606-932-2313
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY56722208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0492219OtherOHIO MEDICAID
KY7100681350Medicaid