Provider Demographics
NPI:1104880624
Name:HUSELTON, JOHN K (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:K
Last Name:HUSELTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 EMPIRE BLVD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-1957
Mailing Address - Country:US
Mailing Address - Phone:585-922-0930
Mailing Address - Fax:585-787-2533
Practice Address - Street 1:2000 EMPIRE BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-1957
Practice Address - Country:US
Practice Address - Phone:585-922-0930
Practice Address - Fax:585-787-2533
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152522207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY110158696OtherRAILROAD MEDICARE
NY01463978Medicaid
NYS76001Medicare PIN
NYB75831Medicare UPIN