Basic Information
| Provider Information | |||||||||
| NPI: | 1609886373 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JUDD | ||||||||
| FirstName: | SONALI | ||||||||
| MiddleName: | KIRAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PATEL | ||||||||
| OtherFirstName: | SONALI | ||||||||
| OtherMiddleName: | KIRAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 152557 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336842557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138769553 | ||||||||
| FaxNumber: | 8138774109 | ||||||||
| Practice Location | |||||||||
| Address1: | 4728 N HABANA AVE | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336147100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138769553 | ||||||||
| FaxNumber: | 8138774109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2006 | ||||||||
| LastUpdateDate: | 06/19/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME91259 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 052602910 | 05 | FL | MEDICAID |