1689680951 NPI number — JACK E HORTON MD

Table of content: JACK E HORTON MD (NPI 1689680951)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689680951 NPI number — JACK E HORTON MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HORTON
Provider First Name:
JACK
Provider Middle Name:
E
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689680951
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 26726
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78755-0726
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-407-8686
Provider Business Mailing Address Fax Number:
512-406-6216

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1807 W SLAUGHTER LN
Provider Second Line Business Practice Location Address:
#490
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78748-6208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-282-8967
Provider Business Practice Location Address Fax Number:
512-292-5143
Provider Enumeration Date:
07/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  J2087 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 116361004 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116361005 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116361002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 116361006 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com