Provider Demographics
NPI:1407988504
Name:HORNE, JOHNATHAN
Entity Type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:
Last Name:HORNE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6362 VINTAGE OAK LN
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6544
Mailing Address - Country:US
Mailing Address - Phone:801-277-2423
Mailing Address - Fax:801-277-2493
Practice Address - Street 1:6362 VINTAGE OAK LN
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-6544
Practice Address - Country:US
Practice Address - Phone:801-277-2423
Practice Address - Fax:801-277-2493
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO26865207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
D07675Medicare UPIN