Basic Information
| Provider Information | |||||||||
| NPI: | 1780646745 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUDSON | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | CAROLYN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2315 W JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325057552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504364630 | ||||||||
| FaxNumber: | 8504362095 | ||||||||
| Practice Location | |||||||||
| Address1: | 5520 STEWART ST | ||||||||
| Address2: | |||||||||
| City: | MILTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325704304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8509819433 | ||||||||
| FaxNumber: | 8509819436 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2006 | ||||||||
| LastUpdateDate: | 08/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME93283 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | U6061Y | 01 | FL | MCR | OTHER | 2728001 00 | 05 | FL | MEDICAID |