Basic Information
| Provider Information | |||||||||
| NPI: | 1487747564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HUSTON | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 99406 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176052833 | ||||||||
| FaxNumber: | 6828853939 | ||||||||
| Practice Location | |||||||||
| Address1: | 6316 PRECINCT LINE RD | ||||||||
| Address2: | |||||||||
| City: | HURST | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760542766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176052500 | ||||||||
| FaxNumber: | 8176052983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 03/17/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | J8890 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1003887985 | 01 | GRP NPI NUMBER | OTHER | 10022305 | 01 | TX | AMERIGROUP PIN | OTHER | 160429004 | 05 | TX | MEDICAID | 5687156 | 01 | TX | AETNA PIN | OTHER | 8M3072 | 01 | TX | BCBSTX IND PIN | OTHER | 160429003 | 05 | TX | MEDICAID | 008YLE | 01 | TX | BCBSTX GRP PIN | OTHER | 1861990 | 01 | TX | CIGNA PIN | OTHER | 080626701 | 05 | TX | MEDICAID | 114571 | 01 | TX | SUPERIOR PIN | OTHER | 1633114101 | 05 | TX | MEDICAID | 2146961 | 01 | TN | FIRSTHEALTH PIN | OTHER |