Provider Demographics
NPI:1780646745
Name:HUDSON, DIANE CAROLYN (MD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:CAROLYN
Last Name:HUDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2315 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32505-7552
Mailing Address - Country:US
Mailing Address - Phone:850-436-4630
Mailing Address - Fax:850-436-2095
Practice Address - Street 1:5520 STEWART ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-4304
Practice Address - Country:US
Practice Address - Phone:850-981-9433
Practice Address - Fax:850-981-9436
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME93283207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU6061YOtherMCR
FL2728001 00Medicaid
F18578Medicare UPIN