Basic Information
Provider Information | |||||||||
NPI: | 1073527180 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOUGH | ||||||||
FirstName: | DAVID | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1690 | ||||||||
Address2: |   | ||||||||
City: | LA PORTE | ||||||||
State: | IN | ||||||||
PostalCode: | 463521690 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2193262312 | ||||||||
FaxNumber: | 2193262584 | ||||||||
Practice Location | |||||||||
Address1: | 7002 W JOHNSON RD | ||||||||
Address2: |   | ||||||||
City: | LA PORTE | ||||||||
State: | IN | ||||||||
PostalCode: | 463508289 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2193250604 | ||||||||
FaxNumber: | 2198791401 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/27/2006 | ||||||||
LastUpdateDate: | 12/05/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 02000556A | IN | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 000000378124 | 01 | IN | ANTHEM, BCBS | OTHER | 100151230 | 05 | IN |   | MEDICAID |