=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689651457
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID C HOUGLUM M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2005
-----------------------------------------------------
Last Update Date | 09/04/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 77 NEALY AVE 1ST MEDICAL GROUP/CD
-----------------------------------------------------
City | LANGLEY AFB
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23665-2040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-764-6969
-----------------------------------------------------
Fax | 757-764-9845
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 77 NEALY AVE
-----------------------------------------------------
City | LANGLEY AFB
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23665-2040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-764-6969
-----------------------------------------------------
Fax | 757-764-9845
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 29582
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------