MEDICARE: JACK LYNWOOD JUDSON, MD

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	C8715	TX

General Provider Information

NPI Number	:	1902298417
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JACK LYNWOOD JUDSON, MD

Provider Business Mailing Address
First Line	:	1800 MALIBAR RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-1834
Country	:	US
Telephone Number	:	817-732-7526
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 MALIBAR RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76116-1834
Country	:	US
Telephone Number	:	817-732-7526
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. JACK LYNWOOD JUDSON
Credential	:	M.D.
Telephone Number	:	817-732-8526

Provider Enumeration Date	:	02/21/2015
Last Update Date	:	02/21/2015

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