Provider Demographics
NPI:1689659039
Name:JUDD, JEFFREY B (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:B
Last Name:JUDD
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Mailing Address - Street 1:11475 OLDE CABIN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7129
Mailing Address - Country:US
Mailing Address - Phone:314-991-8200
Mailing Address - Fax:314-991-8206
Practice Address - Street 1:10010 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2106
Practice Address - Country:US
Practice Address - Phone:314-525-1165
Practice Address - Fax:314-525-1485
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2022-01-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
VA01012410112085R0202X
IL0360796422085R0202X
TN370862085R0202X
KY257292085R0202X
KS04298452085R0202X
WV210742085R0202X
MOR1H832085R0202X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO202637419Medicaid
4964V4964OtherGHP
112315OtherHEALTHLINK
MO1765OtherBCBS
MO1765OtherBCBS