Provider Demographics
NPI:1477504272
Name:DAUMEN, JUDITH REBECCA (MD)
Entity type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:REBECCA
Last Name:DAUMEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:JUDITH
Other - Middle Name:REBECCA
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4414 LAKE BOONE TRAIL
Mailing Address - Street 2:SUITE 103
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607
Mailing Address - Country:US
Mailing Address - Phone:919-787-0266
Mailing Address - Fax:919-571-9314
Practice Address - Street 1:4414 LAKE BOONE TRAIL
Practice Address - Street 2:SUITE 103
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607
Practice Address - Country:US
Practice Address - Phone:919-787-0266
Practice Address - Fax:919-571-9314
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700918208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC012U3OtherBCBS
NC79012U3Medicaid
G67081Medicare UPIN