Provider Demographics
NPI:1154362606
Name:HUDSON, BRIAN D
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:D
Last Name:HUDSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1198
Mailing Address - Street 2:DEPT 03-007RC
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39181-1198
Mailing Address - Country:US
Mailing Address - Phone:601-883-4250
Mailing Address - Fax:
Practice Address - Street 1:2100 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-8211
Practice Address - Country:US
Practice Address - Phone:601-883-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16272207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1560065Medicaid
MS00125435Medicaid
MS512I930263Medicare PIN
MS00125435Medicaid