Provider Demographics
NPI:1164453932
Name:WILSON, JUDITH H (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:H
Last Name:WILSON
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 1:1100 HOLLENBACK LN.
Mailing Address - Street 2:
Mailing Address - City:DEER LODGE
Mailing Address - State:MT
Mailing Address - Zip Code:59722
Mailing Address - Country:US
Mailing Address - Phone:406-846-2212
Mailing Address - Fax:
Practice Address - Street 1:1100 HOLLENBACK LN
Practice Address - Street 2:
Practice Address - City:DEER LODGE
Practice Address - State:MT
Practice Address - Zip Code:59722
Practice Address - Country:US
Practice Address - Phone:406-846-2212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4610173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT92501OtherBCBS
MT28220Medicaid
MT28220Medicaid
MT81646Medicare ID - Type UnspecifiedMEDICARE