Provider Demographics
NPI:1518051788
Name:TRAVIS, JUDY COOKE (MD)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:COOKE
Last Name:TRAVIS
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 1:123 EAST CAPITOL STREET
Mailing Address - Street 2:
Mailing Address - City:DEMOPOLIS
Mailing Address - State:AL
Mailing Address - Zip Code:36732
Mailing Address - Country:US
Mailing Address - Phone:334-289-9408
Mailing Address - Fax:334-289-1160
Practice Address - Street 1:123 EAST CAPITOL STREET
Practice Address - Street 2:
Practice Address - City:DEMOPOLIS
Practice Address - State:AL
Practice Address - Zip Code:36732
Practice Address - Country:US
Practice Address - Phone:334-289-9408
Practice Address - Fax:334-289-1160
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL11061207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL101807Medicaid
AL51082149OtherBLUE CROSS BLUE SHIELD
AL000082149Medicaid
AL0110549OtherRAILROAD MEDICARE
AL0110549OtherRAILROAD MEDICARE
AL000082149Medicaid
AL102I507914Medicare PIN