Healthcare Provider Details

I. General information

NPI: 1083856884
Provider Name (Legal Business Name): SARA NICOLE HOUSTON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 10/13/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 UNIVERSITY DR S
FARGO ND
58103-4940
US

IV. Provider business mailing address

5012 S US HIGHWAY 75 STE 300 ATTN BILLING
DENISON TX
75020-4589
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-3300
  • Fax: 701-364-8906
Mailing address:
  • Phone: 903-416-3790
  • Fax: 903-712-3790

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01071158A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number44987
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number12673
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier18250
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: