Provider Demographics
NPI:1982781506
Name:SOMERVILLE, JUDSON J (M D)
Entity Type:Individual
Prefix:
First Name:JUDSON
Middle Name:J
Last Name:SOMERVILLE
Suffix:
Gender:M
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 1:9114 MCPHERSON RD STE 2508
Mailing Address - Street 2:
Mailing Address - City:LAREDO
Mailing Address - State:TX
Mailing Address - Zip Code:78045-6511
Mailing Address - Country:US
Mailing Address - Phone:956-717-2962
Mailing Address - Fax:956-717-0069
Practice Address - Street 1:9114 MCPHERSON RD STE 2508
Practice Address - Street 2:
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78045-6511
Practice Address - Country:US
Practice Address - Phone:956-717-2962
Practice Address - Fax:956-717-0069
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6622174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124906201Medicaid
TX81X360OtherBLUE CROSS BLUE SHIELD
TX81X360OtherBLUE CROSS BLUE SHIELD
TX81X360Medicare PIN
TX124906201Medicaid