Provider Demographics
NPI:1427021112
Name:HORTON, LISA ANTOINETTE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANTOINETTE
Last Name:HORTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9426 DARTMOUTH RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21045-1809
Mailing Address - Country:US
Mailing Address - Phone:410-740-1314
Mailing Address - Fax:
Practice Address - Street 1:7310 RITCHIE HWY
Practice Address - Street 2:SUITE 516
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-3065
Practice Address - Country:US
Practice Address - Phone:410-761-7305
Practice Address - Fax:410-761-7387
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-11
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD31987208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD38153Medicaid
MDD32582Medicare UPIN