Provider Demographics
NPI:1366470247
Name:HORNELL, ALLEN BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:BRUCE
Last Name:HORNELL
Suffix:
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 1:5450 CLEARFORK MAIN ST STE 430
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-3559
Mailing Address - Country:US
Mailing Address - Phone:817-984-1688
Mailing Address - Fax:817-419-4494
Practice Address - Street 1:5450 CLEARFORK MAIN ST STE 430
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-3559
Practice Address - Country:US
Practice Address - Phone:817-984-1688
Practice Address - Fax:817-419-4494
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK2042207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124164806Medicaid
TX124164801Medicaid
TX8CN892OtherBCBSTX
TX124164801Medicaid
TXP00910171Medicare PIN
080125452OtherMEDICARE RR
G44984Medicare UPIN
TXTXB114986Medicare PIN
TX124164806Medicaid