Healthcare Provider Details

I. General information

NPI: 1962710160
Provider Name (Legal Business Name): W. FORREST JUDSON, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2010
Last Update Date: 01/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 VONDERBURG DR SUITE 310W
BRANDON FL
33511-5964
US

IV. Provider business mailing address

500 VONDERBURG DR SUITE 310W
BRANDON FL
33511-5964
US

V. Phone/Fax

Practice location:
  • Phone: 813-681-8974
  • Fax: 813-689-4573
Mailing address:
  • Phone: 813-681-8974
  • Fax: 813-689-4573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberME26707
License Number StateFL

VIII. Authorized Official

Name: MRS. JUNE A HUEBNER
Title or Position: OFFICE MANAGER
Credential:
Phone: 813-681-8974