Provider Demographics
NPI:1740234657
Name:JUDGE, MOLLY S (DPM)
Entity Type:Individual
Prefix:DR
First Name:MOLLY
Middle Name:S
Last Name:JUDGE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-1935
Mailing Address - Country:US
Mailing Address - Phone:419-732-2618
Mailing Address - Fax:419-732-1998
Practice Address - Street 1:530 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-1935
Practice Address - Country:US
Practice Address - Phone:419-732-2618
Practice Address - Fax:419-732-1998
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.002877213ES0103X
MIL834822213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000142130OtherANTHEM BCBS OH
MI134887318Medicaid
OH2019774Medicaid
MI4855810540OtherBCBS MI
MI0P39580Medicare PIN
MI134887318Medicaid
OH0826574Medicare PIN
OH480030118Medicare PIN
OH4750850001Medicare NSC