Provider Demographics
NPI:1114299104
Name:GARY R. HUSTON D.O., INC
Entity Type:Organization
Organization Name:GARY R. HUSTON D.O., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO,
Authorized Official - Phone:440-593-6551
Mailing Address - Street 1:PO BOX 635
Mailing Address - Street 2:177 WEST ST
Mailing Address - City:CONNEAUT
Mailing Address - State:OH
Mailing Address - Zip Code:44030-0635
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:44030-2153
Practice Address - Country:US
Practice Address - Phone:440-593-6551
Practice Address - Fax:440-593-6522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-00-4562208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0772310Medicaid
OH0772310Medicaid