Provider Demographics
NPI:1215033949
Name:HOUGHTALEN, RORY P (MD)
Entity Type:Individual
Prefix:
First Name:RORY
Middle Name:P
Last Name:HOUGHTALEN
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 1:81 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14608-1410
Mailing Address - Country:US
Mailing Address - Phone:585-368-6900
Mailing Address - Fax:585-423-9523
Practice Address - Street 1:81 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14608-1410
Practice Address - Country:US
Practice Address - Phone:585-368-6900
Practice Address - Fax:585-423-9523
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2015-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1689142084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01214364Medicaid
NYJ400031411/GP BA0017Medicare PIN
NY01214364Medicaid