Healthcare Provider Details

I. General information

NPI: 1720085392
Provider Name (Legal Business Name): CHARLES RAEBURN JUDY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 09/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 RANDOLPH ST
RADFORD VA
24141-2428
US

IV. Provider business mailing address

600 RANDOLPH ST
RADFORD VA
24141-2428
US

V. Phone/Fax

Practice location:
  • Phone: 540-639-5300
  • Fax: 540-639-4653
Mailing address:
  • Phone: 540-639-5300
  • Fax: 540-639-4653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101050262
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: