Provider Demographics
NPI:1528089190
Name:DAVID, JOHN LEWIS JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LEWIS
Last Name:DAVID
Suffix:JR
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 1:6907 JOHN DAVID CIR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79124-1636
Mailing Address - Country:US
Mailing Address - Phone:806-359-3030
Mailing Address - Fax:806-359-8595
Practice Address - Street 1:6907 JOHN DAVID CIR
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79124-1636
Practice Address - Country:US
Practice Address - Phone:806-359-3030
Practice Address - Fax:806-359-8595
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG3273174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX03549120Medicaid
TXQL300Medicare ID - Type Unspecified
TX03549120Medicaid