Provider Demographics
NPI:1043260060
Name:HORAN, MICHAEL J (LICENSED OPTICIAN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:HORAN
Suffix:
Gender:M
Credentials:LICENSED OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-5234
Mailing Address - Country:US
Mailing Address - Phone:401-841-0966
Mailing Address - Fax:401-841-0161
Practice Address - Street 1:73 VALLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-5234
Practice Address - Country:US
Practice Address - Phone:401-841-0966
Practice Address - Fax:401-841-0161
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI189156FX1800X
MA4475156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI2440OtherNHP OF RHODE ISLAND
RI21-02007OtherUNITED HEALTHCARE
RI408112OtherBLUE CHIP,MCHIP,HMOBLUE
RI2490001Medicaid
RI22393-9OtherBCBSRI,HMATE,HMATE2000
RI1316050001Medicare ID - Type Unspecified