Basic Information
Provider Information | |||||||||
NPI: | 1740211911 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HOUCHINS | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3860 W OGDEN AVE | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606232460 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8725883000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3860 W OGDEN AVE | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606232460 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8725883000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/06/2006 | ||||||||
LastUpdateDate: | 05/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 172212-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 7081524 | 05 | WA |   | MEDICAID | 870564069HOU | 01 | UT | EMIA | OTHER | XPY197122 | 05 | CA |   | MEDICAID | 122808100 | 05 | WY |   | MEDICAID | 190475000 | 01 | UT | DEPT OF LABOR | OTHER | 04821 | 01 | UT | UUHSC | OTHER | 1061 | 01 | UT | U HEALTH PLAN | OTHER | 11249 | 01 | UT | DMBA | OTHER | 49934 | 01 | UT | PEHP | OTHER | PRA01489 | 01 | UT | MOLINA | OTHER | QM0000053151 | 01 | UT | ALTIUS | OTHER | 107005326101 | 01 | UT | IHC | OTHER |