Provider Demographics
NPI:1962478602
Name:HUSTON, CHARLES CLOVER III (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:CLOVER
Last Name:HUSTON
Suffix:III
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 1:121 DOCTORS LN
Mailing Address - Street 2:
Mailing Address - City:CLARION
Mailing Address - State:PA
Mailing Address - Zip Code:16214-8515
Mailing Address - Country:US
Mailing Address - Phone:814-226-3470
Mailing Address - Fax:814-226-3479
Practice Address - Street 1:116 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:OIL CITY
Practice Address - State:PA
Practice Address - Zip Code:16301-2736
Practice Address - Country:US
Practice Address - Phone:814-676-0848
Practice Address - Fax:814-677-1289
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD024985E208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0008098500003Medicaid