Provider Demographics
NPI:1366416810
Name:JUDD, KENNETH PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:PATRICK
Last Name:JUDD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1758 TRAVERS WHARF RD
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-9500
Mailing Address - Country:US
Mailing Address - Phone:410-901-9368
Mailing Address - Fax:
Practice Address - Street 1:100 BRAMBLE ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-2408
Practice Address - Country:US
Practice Address - Phone:410-228-8106
Practice Address - Fax:410-228-8390
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD22122207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
877RMedicare ID - Type Unspecified
MDB67179Medicare UPIN