Basic Information
| Provider Information | |||||||||
| NPI: | 1790847994 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUDSON | ||||||||
| FirstName: | M'LISS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847176 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752847176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032371800 | ||||||||
| FaxNumber: | 9032371810 | ||||||||
| Practice Location | |||||||||
| Address1: | 802 MEDICAL DR | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LONGVIEW | ||||||||
| State: | TX | ||||||||
| PostalCode: | 756055100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9037577871 | ||||||||
| FaxNumber: | 9037532479 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 03/30/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/30/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | MD.205535 | LA | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | R8H73 | MO | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | G3482 | TX | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 123023705 | 05 | TX | MEDICAID | 02005302 | 05 | MS | MEDICAID | 2307941 | 05 | LA | MEDICAID |