Provider Demographics
NPI:1447453451
Name:HUDNALL, SHANE (MD)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:
Last Name:HUDNALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1004
Mailing Address - Country:US
Mailing Address - Phone:336-832-7000
Mailing Address - Fax:336-832-7869
Practice Address - Street 1:2630 WILLARD DAIRY RD
Practice Address - Street 2:SUITE 202
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27265-8351
Practice Address - Country:US
Practice Address - Phone:336-884-3770
Practice Address - Fax:336-884-3771
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC141561207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCZR0000135Medicare UPIN