Provider Demographics
NPI:1710296439
Name:TIMOTHY P. HUSTON MD, INC
Entity Type:Organization
Organization Name:TIMOTHY P. HUSTON MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:P
Authorized Official - Last Name:HUSTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-643-9111
Mailing Address - Street 1:31722 AVENIDA EVITA
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-3402
Mailing Address - Country:US
Mailing Address - Phone:949-643-9111
Mailing Address - Fax:949-643-8916
Practice Address - Street 1:27231 LA PAZ RD STE A
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-3627
Practice Address - Country:US
Practice Address - Phone:949-643-9111
Practice Address - Fax:949-643-8916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44816207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty