Provider Demographics
NPI:1104836881
Name:HUSTON, GARY ROBERT (DO)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:ROBERT
Last Name:HUSTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 WEST ST
Mailing Address - Street 2:
Mailing Address - City:CONNEAUT
Mailing Address - State:OH
Mailing Address - Zip Code:44030
Mailing Address - Country:US
Mailing Address - Phone:440-593-6551
Mailing Address - Fax:440-593-6522
Practice Address - Street 1:177 WEST ST
Practice Address - Street 2:
Practice Address - City:CONNEAUT
Practice Address - State:OH
Practice Address - Zip Code:44030
Practice Address - Country:US
Practice Address - Phone:440-593-6551
Practice Address - Fax:440-593-6522
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34004562207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0772310Medicaid
E48125Medicare UPIN
OH0772310Medicaid