Healthcare Provider Details

I. General information

NPI: 1811018492
Provider Name (Legal Business Name): JOHN T HOUSTON MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2707 BRECKENRIDGE ST STE 2
OWENSBORO KY
42303
US

IV. Provider business mailing address

2707 BRECKENRIDGE ST STE 2
OWENSBORO KY
42303
US

V. Phone/Fax

Practice location:
  • Phone: 270-926-8828
  • Fax: 270-926-0760
Mailing address:
  • Phone: 270-926-8828
  • Fax: 270-926-0760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number21411
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA787
License Number StateKY

VIII. Authorized Official

Name: MR. JOHN T HOUSTON
Title or Position: OWNER
Credential: MD
Phone: 270-926-8828