Provider Demographics
NPI:1518964568
Name:HORTON, JACK D (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:D
Last Name:HORTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:8505 ARLINGTON BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031-4621
Mailing Address - Country:US
Mailing Address - Phone:703-698-8525
Mailing Address - Fax:703-849-1918
Practice Address - Street 1:8505 ARLINGTON BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-4621
Practice Address - Country:US
Practice Address - Phone:703-698-8525
Practice Address - Fax:703-849-1918
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2007-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101031625207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
502857OtherNCPPO
541042964OtherCIGNA PPO
541042964OtherHEALTHNET/TRICARE/CHAMPUS
486313OtherAETNA HMO
541042964OtherPHCS
541042964OtherUNITED HEALTHCARE
541042964OtherONE HEALTH PLAN/GREAT WST
4091816OtherAETNA PPO
6975-0005OtherCAREFIRST BCBS
060005780OtherMEDICARE - RAILROAD
VA006050450Medicaid
541042964OtherKAISER
011553OtherANTHEM BCBS/TRIGON
20727OtherMAMSI/ALLIANCE
060005780OtherMEDICARE - RAILROAD
541042964OtherPHCS