Provider Demographics
NPI:1578531323
Name:JUSON, MANUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MANUEL
Middle Name:
Last Name:JUSON
Suffix:
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:PO BOX 8337
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79114-8337
Mailing Address - Country:US
Mailing Address - Phone:806-355-6593
Mailing Address - Fax:806-352-8774
Practice Address - Street 1:1000 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SHAMROCK
Practice Address - State:TX
Practice Address - Zip Code:79079-2820
Practice Address - Country:US
Practice Address - Phone:806-256-2114
Practice Address - Fax:806-352-8774
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ6139207P00000X, 208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF12730Medicare UPIN