Basic Information
| Provider Information | |||||||||
| NPI: | 1902888381 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLISTON | ||||||||
| FirstName: | HUBERT | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 66308 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772666308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 7135234897 | ||||||||
| Practice Location | |||||||||
| Address1: | 4301 GARTH RD | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | BAYTOWN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2814208400 | ||||||||
| FaxNumber: | 7135234897 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 08/26/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E7320 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 121436305 | 05 | TX | MEDICAID | 043929101 | 05 | TX | MEDICAID | 080462703 | 05 | TX | MEDICAID |