Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | E2505 | TX |
N | 2080A0000X | Adolescent Medicine | E2505 | TX |
NPI | 1275582439 |
---|---|
Provider Name | Dr. John Edward Champion |
First Address | Fort Worth, TX 76104-2604 |
Second Address | Fort Worth, TX 76104-2604 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/05/2006 |
Last Update Date | 01/07/2009 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00TD97 | BCBS ID NUMBER (01) | TX |
132990602 | (05) | TX |
132990609 | TEXAS HEALTH STEPS (01) | TX |
4019283 | AETNA HMO PROVIDER ID (01) | TX |