Provider Demographics
NPI:1023073384
Name:HUSTON, JORGE D (OD)
Entity type:Individual
Prefix:DR
First Name:JORGE
Middle Name:D
Last Name:HUSTON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 S CALVARY WAY STE D
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4165
Mailing Address - Country:US
Mailing Address - Phone:928-649-2600
Mailing Address - Fax:928-649-7847
Practice Address - Street 1:522 FINNEY FLAT RD
Practice Address - Street 2:STE K
Practice Address - City:CAMP VERDE
Practice Address - State:AZ
Practice Address - Zip Code:86322
Practice Address - Country:US
Practice Address - Phone:928-567-3330
Practice Address - Fax:928-567-3359
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOPT-000110152W00000X
AZ110152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3892490001Medicare NSC
AZT41763Medicare UPIN
AZZ62231Medicare PIN