Provider Demographics
NPI:1508032327
Name:JUDD, LILITH MARION (MD)
Entity Type:Individual
Prefix:
First Name:LILITH
Middle Name:MARION
Last Name:JUDD
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9135 SW BARNES RD
Practice Address - Street 2:SUITE 461
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6646
Practice Address - Country:US
Practice Address - Phone:503-216-1150
Practice Address - Fax:971-282-0086
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2022-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD605300232084N0400X
CAA1393152084N0400X
ORMD1668542084N0400X, 2084A2900X
AK1151852084N0400X
MT407232084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurocritical Care
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500671980Medicaid
ORP01755105OtherRR MEDICARE (PH&S)-PMG
ORP01755105OtherRR MEDICARE (PH&S)-PMG
ORR192455Medicare PIN
OR500671980Medicaid
ORR176429Medicare PIN