Healthcare Provider Details

I. General information

NPI: 1013237916
Provider Name (Legal Business Name): MARY JENNETTE JUDD M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2010
Last Update Date: 08/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GREEN VALLEY RD STE 304
GREENSBORO NC
27408-7722
US

IV. Provider business mailing address

600 GREEN VALLEY RD STE 304
GREENSBORO NC
27408-7722
US

V. Phone/Fax

Practice location:
  • Phone: 336-282-4840
  • Fax: 336-282-4660
Mailing address:
  • Phone: 336-282-4840
  • Fax: 336-282-4660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number165137
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number51542
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2015-00730
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: