Basic Information
Provider Information | |||||||||
NPI: | 1184694069 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HUDSON | ||||||||
FirstName: | JOY | ||||||||
MiddleName: | DINA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DINA | ||||||||
OtherFirstName: | JOY | ||||||||
OtherMiddleName: | ELLEN | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 410 LAKECREST DR | ||||||||
Address2: |   | ||||||||
City: | SPARTANBURG | ||||||||
State: | SC | ||||||||
PostalCode: | 293015238 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8649087406 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 9098 FAIRFOREST RD | ||||||||
Address2: |   | ||||||||
City: | SPARTANBURG | ||||||||
State: | SC | ||||||||
PostalCode: | 293011134 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8643427070 | ||||||||
FaxNumber: | 8645864327 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/24/2006 | ||||||||
LastUpdateDate: | 01/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/22/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 19782 | SC | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 197824 | 05 | SC |   | MEDICAID | 88022 | 01 | SC | MEDCOST | OTHER | 5005636 | 01 | SC | AETNA | OTHER | 89063MX | 05 | NC |   | MEDICAID |