Basic Information
| Provider Information | |||||||||
| NPI: | 1053315010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BADGWELL | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 162835 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761612835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173340530 | ||||||||
| FaxNumber: | 8173340235 | ||||||||
| Practice Location | |||||||||
| Address1: | 801 7TH AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761042733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828854054 | ||||||||
| FaxNumber: | 6828857497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2005 | ||||||||
| LastUpdateDate: | 05/26/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | D8139 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | V2811 | 05 | NM | MEDICAID | 100128470A | 05 | OK | MEDICAID | 107880102 | 05 | TX | MEDICAID | 107880104 | 01 | TX | FIRSTCARE COMMERICAL | OTHER | 137345809 | 01 | TX | MEDICAID GROUP | OTHER | 140442853 | 01 | TX | CSHCN GROUP | OTHER | 00N47F | 01 | TX | MEDICARE GROUP | OTHER | 201000424 | 01 | NM | PRESBYTERIAN COMMERCIAL | OTHER | B174 | 01 | TRIWEST | OTHER | 129844006 | 05 | TX | MEDICAID | 87249Z | 01 | TX | HMO BLUE | OTHER | 129844011 | 01 | TX | CSHCN | OTHER | 1447220850 | 01 | TX | NPI GROUP | OTHER | 201000424 | 05 | NM | MEDICAID | 129844008 | 05 | TX | MEDICAID | 129844010 | 05 | TX | MEDICAID | 8F0118 | 01 | TX | BC/BS | OTHER |