Provider Demographics
NPI:1619144433
Name:JUDY, DAVID (DO)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:
Last Name:JUDY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:# L-3555
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43260-0001
Mailing Address - Country:US
Mailing Address - Phone:304-925-7546
Mailing Address - Fax:681-205-8369
Practice Address - Street 1:4610 KANAWHA AVE SW
Practice Address - Street 2:SUITE 302
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1320
Practice Address - Country:US
Practice Address - Phone:304-925-7546
Practice Address - Fax:681-205-8369
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2007-00740207N00000X
FLOS 11120207N00000X
WV2596207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810023193Medicaid
WV5679351OtherCIGNA
WV1619144433OtherHEALTHNET/TRICARE
WV1619144433OtherUNITED HEALTHCARE
WV1619144433OtherHEALTHSMART PEIA
WV1619144433OtherUMWA HEALTH PLAN OF WV
WV2707397OtherHIGHMARK BCBS