Healthcare Provider Details

I. General information

NPI: 1043705395
Provider Name (Legal Business Name): ETHAN MARK HUCKABEE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2018
Last Update Date: 06/06/2024
Certification Date: 06/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W JACKSON ST
CARBONDALE IL
62901-1462
US

IV. Provider business mailing address

405 W JACKSON ST
CARBONDALE IL
62901-1462
US

V. Phone/Fax

Practice location:
  • Phone: 618-549-0721
  • Fax:
Mailing address:
  • Phone: 618-549-0721
  • Fax: 618-457-0469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number5101024216
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number5101026802
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036162411
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: