Provider Demographics
NPI:1144257452
Name:JUDY, KEVIN D (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:D
Last Name:JUDY
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 1:909 WALNUT ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:909 WALNUT ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5211
Practice Address - Country:US
Practice Address - Phone:215-955-7000
Practice Address - Fax:215-503-7007
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD034618E207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0012881300001Medicaid
NJ5154502Medicaid
PA0012881300001Medicaid
E51463Medicare UPIN