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General NPI Number Information
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NPI Number | 1902298417
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Entity Type | Organization
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Legal Business Name | JACK LYNWOOD JUDSON, MD
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Dates
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Enumeration Date | 02/21/2015
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Last Update Date | 02/21/2015
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Provider Practice Location Address
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Address Line | 1800 MALIBAR RD
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City | FORT WORTH
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State | TX
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Zip | 76116-1834
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Country | US
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Telephone | 817-732-7526
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Fax |
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Provider Business Mailing Address
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Address Line | 1800 MALIBAR RD
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City | FORT WORTH
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State | TX
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Zip | 76116-1834
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Country | US
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Telephone | 817-732-7526
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JACK LYNWOOD JUDSON
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Credential | M.D.
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Telephone | 817-732-8526
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | C8715
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License Number State | TX
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