Individual
ETHAN MARK HUCKABEE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
405 W JACKSON ST, CARBONDALE, IL 62901-1462
(618) 549-0721
Mailing address
405 W JACKSON ST, CARBONDALE, IL 62901-1462
(618) 549-0721
(618) 457-0469
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
036162411
IL
207P00000X
Emergency Medicine Physician
5101026802
MI
390200000X
Student in an Organized Health Care Education/Training Program
5101024216
MI
Other
Enumeration date
06/28/2018
Last updated
06/06/2024
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