1790839983 NPI number — DR. THERESA MARJORIE HUDSON MD

Table of content: DR. THERESA MARJORIE HUDSON MD (NPI 1790839983)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790839983 NPI number — DR. THERESA MARJORIE HUDSON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HUDSON
Provider First Name:
THERESA
Provider Middle Name:
MARJORIE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HUDSON
Provider Other First Name:
THERESA
Provider Other Middle Name:
PERRY
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1790839983
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 HIGHWAY 34 E
Provider Second Line Business Mailing Address:
BLDG 300
Provider Business Mailing Address City Name:
NEWNAN
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30265-2315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-304-0987
Provider Business Mailing Address Fax Number:
770-251-0938

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2700 HIGHWAY 34 E
Provider Second Line Business Practice Location Address:
BLDG 300
Provider Business Practice Location Address City Name:
NEWNAN
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30265-2315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-304-0987
Provider Business Practice Location Address Fax Number:
770-251-0938
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  039594 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 147556 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000708045C , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




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