Healthcare Provider Details

I. General information

NPI: 1316137961
Provider Name (Legal Business Name): JOHN PATRICK JUDD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 12/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2325 DOUGHERTY FERRY RD STE 206
SAINT LOUIS MO
63122-3356
US

IV. Provider business mailing address

2325 DOUGHERTY FERRY RD STE 206
SAINT LOUIS MO
63122-3356
US

V. Phone/Fax

Practice location:
  • Phone: 314-596-9955
  • Fax: 314-596-9530
Mailing address:
  • Phone: 314-596-9955
  • Fax: 314-596-9530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2011012595
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: