Provider Demographics
NPI:1164412102
Name:HORNER, SAMUEL HARVEY III (OD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:HARVEY
Last Name:HORNER
Suffix:III
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 1:40 2ND ST NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-5009
Mailing Address - Country:US
Mailing Address - Phone:423-476-5341
Mailing Address - Fax:423-472-0321
Practice Address - Street 1:40 2ND ST NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37311-5009
Practice Address - Country:US
Practice Address - Phone:423-476-5341
Practice Address - Fax:423-472-0321
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN000963152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN113503Medicaid
TN113503OtherBLUE CROSS BLUE SHIELD
TN602003553OtherCARITEN SR.
TN35958911Medicare PIN
TN113503OtherBLUE CROSS BLUE SHIELD