Provider Demographics
NPI:1538101928
Name:HORAN, ROGER CLINTON (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:CLINTON
Last Name:HORAN
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 1:4083 N SHILOH DR STE 9
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-5201
Mailing Address - Country:US
Mailing Address - Phone:479-439-1696
Mailing Address - Fax:479-439-1998
Practice Address - Street 1:4083 N SHILOH DR STE 9
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5201
Practice Address - Country:US
Practice Address - Phone:479-439-1696
Practice Address - Fax:479-439-1998
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM88192084N0400X
ARE-60942084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR178868001Medicaid
ID806651200Medicaid
AR5H780F970Medicare PIN
IDH6158Medicare UPIN
ID806651200Medicaid