Provider Demographics
NPI:1407941818
Name:JUDD, DANIEL MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:MARK
Last Name:JUDD
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E HOBSON WAY
Mailing Address - Street 2:
Mailing Address - City:BLYTHE
Mailing Address - State:CA
Mailing Address - Zip Code:92225-1739
Mailing Address - Country:US
Mailing Address - Phone:760-922-0284
Mailing Address - Fax:
Practice Address - Street 1:600 E HOBSONWAY
Practice Address - Street 2:
Practice Address - City:BLYTHE
Practice Address - State:CA
Practice Address - Zip Code:92225-1739
Practice Address - Country:US
Practice Address - Phone:760-922-0284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7236T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0072360Medicaid
T10496Medicare UPIN
SD0072360Medicare ID - Type Unspecified
CASD0072360Medicaid