Provider Demographics
NPI:1841249869
Name:HOUSTON, CHARLES STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:STEPHEN
Last Name:HOUSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:734 N 3RD ST
Mailing Address - Street 2:SUITE 115
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5285
Mailing Address - Country:US
Mailing Address - Phone:352-365-2583
Mailing Address - Fax:352-728-6749
Practice Address - Street 1:801 E DIXIE AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-7601
Practice Address - Country:US
Practice Address - Phone:352-365-2583
Practice Address - Fax:352-728-6749
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME889252085R0202X
FL88925207RM1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207RM1200XAllopathic & Osteopathic PhysiciansInternal MedicineMagnetic Resonance Imaging (MRI)
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00062529OtherRR MEDICARE LMIV
FLP00061039OtherRR MEDICARE RACF
FL273790600Medicaid
FLP00061039OtherRR MEDICARE RACF
FLE50356Medicare UPIN
FL46169ZMedicare PIN