Provider Demographics
NPI:1528152758
Name:JUDY PC
Entity type:Organization
Organization Name:JUDY PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAINE
Authorized Official - Middle Name:DOYLE
Authorized Official - Last Name:JUDY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:208-232-7434
Mailing Address - Street 1:500 S 11TH AVE
Mailing Address - Street 2:STE 501
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-232-7434
Mailing Address - Fax:208-233-6446
Practice Address - Street 1:500 S 11TH AVE
Practice Address - Street 2:STE 501
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-232-7434
Practice Address - Fax:208-233-6446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDC143842208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8N074OtherBLUE CROSS OF IDAHO
ID806327500Medicaid
ID806327500Medicaid
G85624Medicare UPIN