Provider Demographics
NPI:1457357618
Name:MAMACLAY, JUDY D (MD)
Entity Type:Individual
Prefix:
First Name:JUDY
Middle Name:D
Last Name:MAMACLAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 HERON RD
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-3253
Mailing Address - Country:US
Mailing Address - Phone:860-536-6442
Mailing Address - Fax:860-536-6442
Practice Address - Street 1:3 HERON RD
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-3253
Practice Address - Country:US
Practice Address - Phone:860-536-6442
Practice Address - Fax:860-536-6442
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040859207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001408592Medicaid
H77352Medicare UPIN
110009920Medicare PIN