Provider Demographics
NPI:1003844101
Name:HOUSTON, THADDEUS DREXEL (MD)
Entity Type:Individual
Prefix:
First Name:THADDEUS
Middle Name:DREXEL
Last Name:HOUSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5823
Mailing Address - Country:US
Mailing Address - Phone:704-334-7800
Mailing Address - Fax:704-414-7512
Practice Address - Street 1:1701 EAST BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5823
Practice Address - Country:US
Practice Address - Phone:704-334-7800
Practice Address - Fax:704-414-7512
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-020682085R0202X
SC330232085R0202X
MI43010955982085R0202X
IDM-104712085R0202X
LAMD 2025622085R0202X
MN524622085R0202X
VA01012462772085R0202X
AZ326842085R0202X
FLME 999072085R0202X
NMMD2009-01522085R0202X
NJ25MA077906002085R0202X
GA0633542085R0202X
NY230879-12085R0202X
KY428562085R0202X
PAMD4381672085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD7745055200Medicaid
NC5914660Medicaid
NC1570NOtherBCBS-NC
MD143775ZCL9Medicare PIN
NC2075808Medicare PIN