Provider Demographics
NPI:1275523714
Name:HORNER, CHARLES RAYMOND JR (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:RAYMOND
Last Name:HORNER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4721 W 6TH AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074-1549
Mailing Address - Country:US
Mailing Address - Phone:405-743-0550
Mailing Address - Fax:
Practice Address - Street 1:4721 W 6TH AVE STE 130
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074-1549
Practice Address - Country:US
Practice Address - Phone:405-743-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK194452085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
G75229Medicare UPIN