Provider Demographics
NPI: | 1801822911 |
---|---|
Name: | HOUSTON, MARC R (DO) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MARC |
Middle Name: | R |
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 2505 |
Mailing Address - Street 2: | |
Mailing Address - City: | SALEM |
Mailing Address - State: | OR |
Mailing Address - Zip Code: | 97308-2505 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 888-828-3198 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 665 WINTER ST SE |
Practice Address - Street 2: | |
Practice Address - City: | SALEM |
Practice Address - State: | OR |
Practice Address - Zip Code: | 97301-3919 |
Practice Address - Country: | US |
Practice Address - Phone: | 503-561-5634 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-23 |
Last Update Date: | 2007-12-19 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OR | DO25184 | 207P00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207P00000X | Allopathic & Osteopathic Physicians | Emergency Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OR | 277885 | Medicaid | |
277885 | Other | MARION POLK CHP | |
I15163 | Other | PROVIDENCE | |
I15163 | Other | GROUP HEALTH | |
0142246 | Other | WA L&I | |
WA | 8416935 | Medicaid | |
CA | XYP202200 | Medicaid | |
0142246 | Other | WA L&I | |
I15163 | Other | GROUP HEALTH | |
I15163 | Other | PROVIDENCE |