Provider Demographics
NPI:1124012471
Name:JUDGE, MARY ELLEN (OD)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:JUDGE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-5613
Mailing Address - Country:US
Mailing Address - Phone:570-704-0300
Mailing Address - Fax:
Practice Address - Street 1:679 KIDDER ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6908
Practice Address - Country:US
Practice Address - Phone:570-825-3491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE006896T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0070462900002Medicaid