MEDICARE: DR. JACK LEEGON JOHNSON JR. M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	H5576	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0047LP	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1801859996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JACK LEEGON JOHNSON JR. M.D.

Provider Business Mailing Address
First Line	:	560 W MAIN ST
Second Line	:	SUITE 100
City	:	LEWISVILLE
State	:	TX
Zip	:	75057-3629
Country	:	US
Telephone Number	:	972-436-9797
Fax Number	:	972-436-9790

Provider Business Practice Location Address
First Line	:	560 W MAIN ST
Second Line	:	SUITE 100
City	:	LEWISVILLE
State	:	TX
Zip	:	75057-3629
Country	:	US
Telephone Number	:	972-436-9797
Fax Number	:	972-436-9790

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	06/21/2012

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