Healthcare Provider Details

I. General information

NPI: 1578531323
Provider Name (Legal Business Name): MANUEL JUSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2006
Last Update Date: 10/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S MAIN ST
SHAMROCK TX
79079-2820
US

IV. Provider business mailing address

PO BOX 8337
AMARILLO TX
79114-8337
US

V. Phone/Fax

Practice location:
  • Phone: 806-256-2114
  • Fax: 806-352-8774
Mailing address:
  • Phone: 806-355-6593
  • Fax: 806-352-8774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberJ6139
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberJ6139
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberJ6139
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: