Provider Demographics
NPI:1487626594
Name:WATERBURY, JUDE T (MD)
Entity Type:Individual
Prefix:
First Name:JUDE
Middle Name:T
Last Name:WATERBURY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2382 MARITIME DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-3659
Mailing Address - Country:US
Mailing Address - Phone:916-691-6622
Mailing Address - Fax:916-691-6629
Practice Address - Street 1:2382 MARITIME DR STE 100
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-3659
Practice Address - Country:US
Practice Address - Phone:916-691-6622
Practice Address - Fax:916-691-6629
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA90991207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI26696Medicare UPIN