=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962710160
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | W. FORREST JUDSON, MD, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/22/2010
-----------------------------------------------------
Last Update Date | 01/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 500 VONDERBURG DR SUITE 310W
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-5964
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-681-8974
-----------------------------------------------------
Fax | 813-689-4573
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 VONDERBURG DR SUITE 310W
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-5964
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-681-8974
-----------------------------------------------------
Fax | 813-689-4573
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. JUNE A HUEBNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-681-8974
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | ME26707
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------