Provider Demographics
NPI:1780809848
Name:ANDERSON, JUDITH RAYE (MD)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:RAYE
Last Name:ANDERSON
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 1:2125 26TH AVENUE CT
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-6618
Mailing Address - Country:US
Mailing Address - Phone:970-330-6034
Mailing Address - Fax:
Practice Address - Street 1:2125 26TH AVENUE CT
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6618
Practice Address - Country:US
Practice Address - Phone:970-330-6034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO62693207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COD24784Medicare UPIN