Provider Demographics
NPI:1447568225
Name:LAKECREST MEDICAL PLLC
Entity Type:Organization
Organization Name:LAKECREST MEDICAL PLLC
Other - Org Name:WELDON JOHNSON JR, D.O.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:WELDON
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:972-475-1351
Mailing Address - Street 1:7617 LAKEVIEW PKWY
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-4356
Mailing Address - Country:US
Mailing Address - Phone:972-475-1351
Mailing Address - Fax:
Practice Address - Street 1:7617 LAKEVIEW PKWY
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-4356
Practice Address - Country:US
Practice Address - Phone:972-475-1351
Practice Address - Fax:972-412-8220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH1113207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0919714-01Medicaid
TX0919714-01Medicaid
TX00QM21Medicare PIN