Provider Demographics
NPI:1003018284
Name:WAKEFIELD, JOHNNY LEE (DC)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:LEE
Last Name:WAKEFIELD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26603 I-45 NORTH
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77380
Mailing Address - Country:US
Mailing Address - Phone:281-367-6900
Mailing Address - Fax:
Practice Address - Street 1:26603 I-45 NORTH
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77380
Practice Address - Country:US
Practice Address - Phone:281-367-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6399111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX63999OtherDC LICENSE