Provider Demographics
NPI:1790740280
Name:JUDSON, PRESTON LYMAN (MD)
Entity Type:Individual
Prefix:
First Name:PRESTON
Middle Name:LYMAN
Last Name:JUDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 MEADE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4259
Mailing Address - Country:US
Mailing Address - Phone:757-925-0759
Mailing Address - Fax:757-934-9377
Practice Address - Street 1:2000 MEADE PARKWAY
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4259
Practice Address - Country:US
Practice Address - Phone:757-925-0759
Practice Address - Fax:757-934-9377
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101032550207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6024874Medicaid
NC890583HMedicaid
NY02082828Medicaid
VA110090754OtherRAILROAD MEDICARE
VA6024874Medicaid
D80402Medicare UPIN