Provider Demographics
NPI:1518966795
Name:NICKRAS, JUDITH GARLOUGH (MD)
Entity Type:Individual
Prefix:MS
First Name:JUDITH
Middle Name:GARLOUGH
Last Name:NICKRAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:JUDITH
Other - Middle Name:ANN
Other - Last Name:NICKRAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:530 CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2718
Mailing Address - Country:US
Mailing Address - Phone:937-339-3838
Mailing Address - Fax:937-335-1232
Practice Address - Street 1:530 CRESCENT DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2718
Practice Address - Country:US
Practice Address - Phone:937-339-3838
Practice Address - Fax:937-335-1232
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35036285N207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0384230Medicaid
A77526Medicare UPIN
OHN10446642Medicare ID - Type Unspecified