Provider Demographics
NPI:1043700685
Name:HAUSE, DESTINY J (MD)
Entity Type:Individual
Prefix:DR
First Name:DESTINY
Middle Name:J
Last Name:HAUSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1447 W FRY ST APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-5431
Mailing Address - Country:US
Mailing Address - Phone:404-822-4779
Mailing Address - Fax:
Practice Address - Street 1:1120 W MICHIGAN ST # CL642
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5209
Practice Address - Country:US
Practice Address - Phone:404-822-4779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program