Provider Demographics
NPI:1518012632
Name:SON, JUDITH O (MD)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:O
Last Name:SON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JUDITH
Other - Middle Name:R
Other - Last Name:OGAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 12389
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98508-2389
Mailing Address - Country:US
Mailing Address - Phone:360-528-2100
Mailing Address - Fax:360-528-2104
Practice Address - Street 1:404 BLACK HILLS LN SW STE D
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8148
Practice Address - Country:US
Practice Address - Phone:360-528-2100
Practice Address - Fax:360-528-2104
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD 00034244207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1025053Medicaid
WA107850OtherREGENCE
WA110211856OtherRAILROAD MEDICARE
WA136113OtherLABOR & INDUSTRIES
G40797Medicare UPIN
WAGAB16928Medicare PIN