Basic Information
| Provider Information | |||||||||
| NPI: | 1851349195 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUDSON | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5565 GROSSMONT CENTER DR STE 551 | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008982020 | ||||||||
| FaxNumber: | 5053445404 | ||||||||
| Practice Location | |||||||||
| Address1: | 5565 GROSSMONT CENTER DR. | ||||||||
| Address2: | BLDG3 STE 551 | ||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919429194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008982020 | ||||||||
| FaxNumber: | 8448973788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 24189 | AZ | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | G76091 | CA | Y | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | MD2014-0974 | NM | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207WX0107X | MD2014-0974 | NM | N |
ID Information
| ID | Type | State | Issuer | Description | 343955 | 01 | AZ | AHCCCS | OTHER | 55109039 | 05 | NM | MEDICAID | 2629305001 | 01 | AZ | CIGNA | OTHER | 629190 | 01 | AZ | AETNA | OTHER | AZ0392720 | 01 | AZ | BLUE CROSS/ BLUE SHIELD | OTHER |