Provider Demographics
NPI:1063416642
Name:JUDGE, SUTINDERPAL S (MD)
Entity type:Individual
Prefix:DR
First Name:SUTINDERPAL
Middle Name:S
Last Name:JUDGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 NILES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-3270
Mailing Address - Country:US
Mailing Address - Phone:269-429-1085
Mailing Address - Fax:269-429-2202
Practice Address - Street 1:2550 NILES RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-429-1085
Practice Address - Fax:269-429-2202
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-10
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301074135174400000X, 207K00000X
IN01079577A174400000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4650649Medicaid
MIY12563Medicare UPIN
MI4650649Medicaid