Healthcare Provider Details

I. General information

NPI: 1619144433
Provider Name (Legal Business Name): DAVID JUDY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2008
Last Update Date: 10/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4610 KANAWHA AVE SW SUITE 302
CHARLESTON WV
25309-1320
US

IV. Provider business mailing address

# L-3555
COLUMBUS OH
43260-0001
US

V. Phone/Fax

Practice location:
  • Phone: 304-925-7546
  • Fax: 681-205-8369
Mailing address:
  • Phone: 304-925-7546
  • Fax: 681-205-8369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2007-00740
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberOS 11120
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2596
License Number StateWV
# 4
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number2596
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: