Provider Demographics
NPI:1649593625
Name:JORGE D HUSTON OD PLC
Entity Type:Organization
Organization Name:JORGE D HUSTON OD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:PAM
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-567-3330
Mailing Address - Street 1:522 W FINNIE FLAT RD STE K
Mailing Address - Street 2:
Mailing Address - City:CAMP VERDE
Mailing Address - State:AZ
Mailing Address - Zip Code:86322-7265
Mailing Address - Country:US
Mailing Address - Phone:928-567-3330
Mailing Address - Fax:
Practice Address - Street 1:522 W FINNIE FLAT RD STE K
Practice Address - Street 2:
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322-7265
Practice Address - Country:US
Practice Address - Phone:928-567-3330
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-05
Last Update Date:2010-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ110152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZT41763Medicare UPIN
AZ3892490001Medicare NSC
AZZ62231Medicare PIN