Provider Demographics
NPI:1902298417
Name:JACK LYNWOOD JUDSON, MD
Entity Type:Organization
Organization Name:JACK LYNWOOD JUDSON, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:LYNWOOD
Authorized Official - Last Name:JUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-732-8526
Mailing Address - Street 1:1800 MALIBAR RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-1834
Mailing Address - Country:US
Mailing Address - Phone:817-732-7526
Mailing Address - Fax:
Practice Address - Street 1:1800 MALIBAR RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-1834
Practice Address - Country:US
Practice Address - Phone:817-732-7526
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-21
Last Update Date:2015-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXC8715207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty