Provider Demographics
NPI:1265627756
Name:HOUSER, KYLE D (MED, MA, CBIST)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:D
Last Name:HOUSER
Suffix:
Gender:M
Credentials:MED, MA, CBIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 GRACE AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-2115
Mailing Address - Country:US
Mailing Address - Phone:315-331-9666
Mailing Address - Fax:315-331-1663
Practice Address - Street 1:402 GRACE AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-2115
Practice Address - Country:US
Practice Address - Phone:315-331-9666
Practice Address - Fax:315-331-1663
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-08
Last Update Date:2007-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01799320Medicaid