Provider Demographics
NPI:1700248507
Name:AULL, JUDITH (LMT)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:AULL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-5410
Mailing Address - Country:US
Mailing Address - Phone:631-539-7422
Mailing Address - Fax:
Practice Address - Street 1:74 BROADWAY
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-5410
Practice Address - Country:US
Practice Address - Phone:631-539-7422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029429-1208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice