Healthcare Provider Details

I. General information

NPI: 1225324569
Provider Name (Legal Business Name): AMANDA GROEBL JUDILLA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2011
Last Update Date: 04/10/2023
Certification Date: 04/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 N VIRGINIA AVE
EUREKA MO
63025-1115
US

IV. Provider business mailing address

515 N VIRGINIA AVE
EUREKA MO
63025-1115
US

V. Phone/Fax

Practice location:
  • Phone: 636-587-3000
  • Fax:
Mailing address:
  • Phone: 636-587-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2014015412
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: