Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223G0001X | General Practice | 08922 | IA |
Y | 213EG0000X | General Practice | 08922 | IA |
NPI | 1003171497 |
---|---|
Provider Name | Dr. Kelly Michael Huston |
First Address | Ottumwa, IA 52501-2069 |
Second Address | Ottumwa, IA 52501-3027 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/07/2012 |
Last Update Date | 11/07/2012 |