Provider Demographics
NPI:1558463422
Name:DERON HORMAN, M.D., INC
Entity Type:Organization
Organization Name:DERON HORMAN, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERON
Authorized Official - Middle Name:L
Authorized Official - Last Name:HORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-738-3317
Mailing Address - Street 1:1015 S BLACKHOOF ST
Mailing Address - Street 2:PO BOX 37
Mailing Address - City:WAPAKONETA
Mailing Address - State:OH
Mailing Address - Zip Code:45895-2209
Mailing Address - Country:US
Mailing Address - Phone:419-738-3317
Mailing Address - Fax:419-738-5952
Practice Address - Street 1:1015 S BLACKHOOF ST
Practice Address - Street 2:
Practice Address - City:WAPAKONETA
Practice Address - State:OH
Practice Address - Zip Code:45895-2209
Practice Address - Country:US
Practice Address - Phone:419-738-3317
Practice Address - Fax:419-738-5952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067435207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2055430Medicaid
OHDE9362791Medicare PIN
OH2055430Medicaid