Provider Demographics
NPI:1871574806
Name:JUDD, RUSSELL L (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:L
Last Name:JUDD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5317 E 16TH ST
Mailing Address - Street 2:STE 5
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46218-4897
Mailing Address - Country:US
Mailing Address - Phone:317-322-8384
Mailing Address - Fax:317-357-9070
Practice Address - Street 1:5317 E 16TH ST
Practice Address - Street 2:STE 5
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-4897
Practice Address - Country:US
Practice Address - Phone:317-322-8384
Practice Address - Fax:317-357-9070
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01018058174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN338470Medicare ID - Type Unspecified
IND94485Medicare UPIN