Healthcare Provider Details

I. General information

NPI: 1831333186
Provider Name (Legal Business Name): WAYNE B. HOUSTON, M.D., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2009
Last Update Date: 04/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4570 SAN JUAN AVE SUITE 2
JACKSONVILLE FL
32210-2051
US

IV. Provider business mailing address

4570 SAN JUAN AVE SUITE 2
JACKSONVILLE FL
32210-2051
US

V. Phone/Fax

Practice location:
  • Phone: 904-388-8844
  • Fax:
Mailing address:
  • Phone: 904-388-8844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME0055161
License Number StateFL

VIII. Authorized Official

Name: DR. WAYNE BRADLEY HOUSTON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 904-388-8844