Healthcare Provider Details

I. General information

NPI: 1740234657
Provider Name (Legal Business Name): MOLLY S JUDGE DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 11/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 WASHINGTON ST
PORT CLINTON OH
43452-1935
US

IV. Provider business mailing address

530 WASHINGTON ST
PORT CLINTON OH
43452-1935
US

V. Phone/Fax

Practice location:
  • Phone: 419-732-2618
  • Fax: 419-732-1998
Mailing address:
  • Phone: 419-732-2618
  • Fax: 419-732-1998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberL834822
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number36.002877
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: