Provider Demographics
NPI:1275582439
Name:CHAMPION, JOHN EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:EDWARD
Last Name:CHAMPION
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:800 8TH AVE
Mailing Address - Street 2:SUITE 532
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2604
Mailing Address - Country:US
Mailing Address - Phone:817-335-4005
Mailing Address - Fax:817-332-3369
Practice Address - Street 1:800 8TH AVE
Practice Address - Street 2:SUITE 532
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2604
Practice Address - Country:US
Practice Address - Phone:817-335-4005
Practice Address - Fax:817-332-3369
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXE2505208000000X, 207QA0000X, 207RA0000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX132990609OtherTEXAS HEALTH STEPS
TX132990602Medicaid
TX4019283OtherAETNA HMO PROVIDER ID
TX00TD97OtherBCBS ID NUMBER