Provider Demographics
NPI:1902094246
Name:MACHANNAFORD, JUAN C (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:C
Last Name:MACHANNAFORD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11970 N CENTRAL EXPY STE 510
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3961
Mailing Address - Country:US
Mailing Address - Phone:214-575-5885
Mailing Address - Fax:907-782-4662
Practice Address - Street 1:11970 N CENTRAL EXPY STE 510
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3961
Practice Address - Country:US
Practice Address - Phone:214-575-5885
Practice Address - Fax:907-782-4662
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP8154208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00738774OtherRAILROAD MEDICARE
OH2769820Medicaid
WV3810007725Medicaid
KY7100080460Medicaid
TXP8154OtherTEXAS MEDICAL LICENSE
WV3810007725Medicaid
TXP8154OtherTEXAS MEDICAL LICENSE