Provider Demographics
NPI:1154482230
Name:HORNACK, FREDERICK MATHEW JR (OD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:MATHEW
Last Name:HORNACK
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:NC
Mailing Address - Zip Code:28164-1657
Mailing Address - Country:US
Mailing Address - Phone:704-263-5942
Mailing Address - Fax:
Practice Address - Street 1:204 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:STANLEY
Practice Address - State:NC
Practice Address - Zip Code:28164
Practice Address - Country:US
Practice Address - Phone:704-263-2020
Practice Address - Fax:704-263-2011
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC 1119152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909421Medicaid
NC8909421Medicaid