MEDICARE: DR. JORGE D HUSTON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	OPT-000110	AZ
2	152W00000X	Optometrist	110	AZ

General Provider Information

NPI Number	:	1023073384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORGE D HUSTON O.D.

Provider Business Mailing Address
First Line	:	401 S CALVARY WAY STE D
Second Line	:
City	:	COTTONWOOD
State	:	AZ
Zip	:	86326-4165
Country	:	US
Telephone Number	:	928-649-2600
Fax Number	:	928-649-7847

Provider Business Practice Location Address
First Line	:	522 FINNEY FLAT RD
Second Line	:	STE K
City	:	CAMP VERDE
State	:	AZ
Zip	:	86322
Country	:	US
Telephone Number	:	928-567-3330
Fax Number	:	928-567-3359

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	12/28/2022

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