Provider Demographics
NPI:1114942174
Name:WULLER, JUDITH L (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:L
Last Name:WULLER
Suffix:
Gender:F
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:PO BOX 8882
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-0882
Mailing Address - Country:US
Mailing Address - Phone:817-451-4208
Mailing Address - Fax:
Practice Address - Street 1:211 S 3RD ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1915
Practice Address - Country:US
Practice Address - Phone:618-234-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0008232070OtherBLUECROSS BLUESHIELD
IL08232204OtherBLUE CROSS BLUE SHIELD
IL06032182OtherBLUE CROSS BLUE SHIELD
IL08232205OtherBLUE CROSS BLUE SHIELD
ILK28769Medicare PIN
IL06032182OtherBLUE CROSS BLUE SHIELD
ILK29109Medicare PIN
ILK29009Medicare PIN