Provider Demographics
NPI:1639151392
Name:HUSTON, JOHN THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:THEODORE
Last Name:HUSTON
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 1:1299 OLENTANGY RIVER RD
Mailing Address - Street 2:STE 103
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43212-3135
Mailing Address - Country:US
Mailing Address - Phone:614-566-4278
Mailing Address - Fax:614-566-5424
Practice Address - Street 1:3773 OLENTANGY RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3425
Practice Address - Country:US
Practice Address - Phone:614-566-5356
Practice Address - Fax:614-566-3835
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35025062207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0129202Medicaid
OH0129202Medicaid