Provider Demographics
NPI:1801093877
Name:SEVERSON, JUDSON MALCOME (DO)
Entity type:Individual
Prefix:
First Name:JUDSON
Middle Name:MALCOME
Last Name:SEVERSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-8800
Mailing Address - Fax:
Practice Address - Street 1:1700 UNIVERSITY DR E
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-2661
Practice Address - Country:US
Practice Address - Phone:979-691-3300
Practice Address - Fax:979-691-3527
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-02
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM3384207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198296905Medicaid
TX198296904Medicaid
TX198296903Medicaid
TX198296908Medicaid
TXP00799975OtherRAILROAD MEDICARE #
TX8DE548OtherBC/BS#
TX198296903Medicaid
TX198296908Medicaid
TX8DE548OtherBC/BS#
TXTXB153776Medicare PIN
TX8L1016Medicare PIN