Basic Information
| Provider Information | |||||||||
| NPI: | 1124288915 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUSTON | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 611 W. PARK ST. | ||||||||
| Address2: | BWPC | ||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 61801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173836941 | ||||||||
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| Practice Location | |||||||||
| Address1: | 611 W PARK ST | ||||||||
| Address2: | |||||||||
| City: | URBANA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 618012500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173833270 | ||||||||
| FaxNumber: | 2173834116 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2008 | ||||||||
| LastUpdateDate: | 08/06/2016 | ||||||||
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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 | 2085B0100X | 269667 | NY | N | Allopathic & Osteopathic Physicians | Radiology | Body Imaging | 2085N0700X | 269667 | NY | N | Allopathic & Osteopathic Physicians | Radiology | Neuroradiology | 2085R0202X | 55374 | WI | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 036139273 | IL | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 03583575 | 05 | NY | MEDICAID |