Provider Demographics
NPI:1295264307
Name:JUDGE, CLARK E (MD)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:E
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 1:100 BRICKHILL AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-1999
Mailing Address - Country:US
Mailing Address - Phone:207-773-1728
Mailing Address - Fax:
Practice Address - Street 1:100 BRICKHILL AVE STE 201
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1999
Practice Address - Country:US
Practice Address - Phone:207-773-1728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-12
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT74011208800000X
IL125.070949208800000X
MEMD28197208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology