Basic Information
| Provider Information | |||||||||
| NPI: | 1841201274 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOUSTON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | TEMPLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5320 HWY 90 SERVICE ROAD | ||||||||
| Address2: | |||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 36619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516021667 | ||||||||
| FaxNumber: | 2516025660 | ||||||||
| Practice Location | |||||||||
| Address1: | 2423 SCHILLINGER RD S | ||||||||
| Address2: | STE 103 | ||||||||
| City: | MOBILE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 366954136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2516335782 | ||||||||
| FaxNumber: | 2516335364 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 06/19/2008 | ||||||||
| 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 | 207Q00000X | ME76790 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036095495 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 21707 | AL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 051542410 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER |