Basic Information
| Provider Information | |||||||||
| NPI: | 1831194919 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUDAK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6301 UNIVERSITY COMMONS | ||||||||
| Address2: | STE 230 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466351571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742512100 | ||||||||
| FaxNumber: | 5742512151 | ||||||||
| Practice Location | |||||||||
| Address1: | 6301 UNIVERSITY COMMONS | ||||||||
| Address2: | STE 350 | ||||||||
| City: | SOUTH BEND | ||||||||
| State: | IN | ||||||||
| PostalCode: | 466351571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742344100 | ||||||||
| FaxNumber: | 5742821739 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2005 | ||||||||
| LastUpdateDate: | 08/25/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 01033777A | IN | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 000000086163 | 01 | ANTHEM | OTHER | 100357400 | 05 | IN | MEDICAID | 264180DD | 01 | IN | MEDICARE PTAN | OTHER |