Provider Demographics
NPI:1467441931
Name:HORNER, KERRY ALAN (OD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:ALAN
Last Name:HORNER
Suffix:
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 1:1011 SYLVAN AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-1692
Mailing Address - Country:US
Mailing Address - Phone:209-575-2020
Mailing Address - Fax:209-758-5693
Practice Address - Street 1:1011 SYLVAN AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-1692
Practice Address - Country:US
Practice Address - Phone:209-575-2020
Practice Address - Fax:209-758-5693
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5405T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0054050Medicaid
410043677Medicare ID - Type UnspecifiedRAILROAD
SD0054050Medicare ID - Type Unspecified
CASD0054050Medicaid