Provider Demographics
NPI:1124091129
Name:HUSTON, TIMOTHY P (MD)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:P
Last Name:HUSTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:26522 LA ALAMEDA
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6330
Mailing Address - Country:US
Mailing Address - Phone:949-282-1671
Mailing Address - Fax:949-367-0518
Practice Address - Street 1:27231 LA PAZ RD
Practice Address - Street 2:#A
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-3627
Practice Address - Country:US
Practice Address - Phone:949-643-9111
Practice Address - Fax:949-643-8916
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG44816207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEX894ZMedicare PIN
A49762Medicare UPIN
CAEX894YMedicare PIN
CAWG44816AMedicare PIN