Provider Demographics
NPI:1285629907
Name:HOUSTON, BRUCE G (DO)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:G
Last Name:HOUSTON
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:PO BOX 505
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31702-0505
Mailing Address - Country:US
Mailing Address - Phone:229-889-9367
Mailing Address - Fax:229-317-0678
Practice Address - Street 1:2002 PALMYRA RD
Practice Address - Street 2:SUITE 101
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1591
Practice Address - Country:US
Practice Address - Phone:229-889-9367
Practice Address - Fax:229-317-0678
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033166207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA110182702OtherRR MEDICARE PROVIDER #
GA000434772BMedicaid
GA08BDPRXMedicare PIN
GA000434772BMedicaid