Provider Demographics
NPI:1932175973
Name:JUDGE, LISA M (M D)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:JUDGE
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 TWIN CITIES BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1055
Mailing Address - Country:US
Mailing Address - Phone:850-729-1414
Mailing Address - Fax:
Practice Address - Street 1:552 TWIN CITIES BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-1055
Practice Address - Country:US
Practice Address - Phone:850-729-1414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0068524207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00635454OtherRR MEMBER PTAN
FL28955Medicare ID - Type Unspecified
P00635454OtherRR MEMBER PTAN