Provider Demographics
NPI:1821190059
Name:JUDGE, DANIEL GERARD (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:GERARD
Last Name:JUDGE
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 1:11869 RANGE LINE RD
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-9205
Mailing Address - Country:US
Mailing Address - Phone:269-471-7537
Mailing Address - Fax:
Practice Address - Street 1:31 N SAINT JOSEPH AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2207
Practice Address - Country:US
Practice Address - Phone:269-687-1448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052510207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI102025370Medicaid
MI050046347OtherCHAMPS
MIDJ052510OtherBCBSMI
MI0M30900001Medicare PIN
MI102025370Medicaid
MI0M30900Medicare PIN