Healthcare Provider Details

I. General information

NPI: 1134863590
Provider Name (Legal Business Name): INDIANA XAVIER JUDY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MELLON WAY
LATROBE PA
15650-1197
US

IV. Provider business mailing address

1 MELLON WAY
LATROBE PA
15650-1197
US

V. Phone/Fax

Practice location:
  • Phone: 724-832-4095
  • Fax: 724-830-8613
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberOS024945
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: