Basic Information
Provider Information | |||||||||
NPI: | 1801093877 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SEVERSON | ||||||||
FirstName: | JUDSON | ||||||||
MiddleName: | MALCOME | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 844658 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752844658 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2547248800 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1700 UNIVERSITY DR E | ||||||||
Address2: |   | ||||||||
City: | COLLEGE STATION | ||||||||
State: | TX | ||||||||
PostalCode: | 778402661 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9796913300 | ||||||||
FaxNumber: | 9796913527 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/02/2007 | ||||||||
LastUpdateDate: | 10/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | M3384 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 198296905 | 05 | TX |   | MEDICAID | 198296904 | 05 | TX |   | MEDICAID | 198296903 | 05 | TX |   | MEDICAID | 198296908 | 05 | TX |   | MEDICAID | P00799975 | 01 | TX | RAILROAD MEDICARE # | OTHER | 8DE548 | 01 | TX | BC/BS# | OTHER |