Provider Demographics
NPI:1518937242
Name:SMITH, JUDSON D (EDD)
Entity Type:Individual
Prefix:DR
First Name:JUDSON
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4909
Mailing Address - Country:US
Mailing Address - Phone:207-942-3816
Mailing Address - Fax:207-561-4725
Practice Address - Street 1:62 ELM ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-3091
Practice Address - Country:US
Practice Address - Phone:207-553-7056
Practice Address - Fax:207-773-2082
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS352103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME098303OtherANTHEM LEGACY NUMBER
MEME0801Medicare ID - Type UnspecifiedMEDICARE PROVIDER #