Provider Demographics
NPI:1619074051
Name:HORN, RANDAL J (MD)
Entity Type:Individual
Prefix:
First Name:RANDAL
Middle Name:J
Last Name:HORN
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 1:2217 S SYCAMORE ST
Mailing Address - Street 2:
Mailing Address - City:PALESTINE
Mailing Address - State:TX
Mailing Address - Zip Code:75801-4786
Mailing Address - Country:US
Mailing Address - Phone:903-729-3993
Mailing Address - Fax:
Practice Address - Street 1:2217 S SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:PALESTINE
Practice Address - State:TX
Practice Address - Zip Code:75801-4786
Practice Address - Country:US
Practice Address - Phone:903-729-3993
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRH069032207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3308090Medicaid
MIC20578OtherRAILROAD MEDICARE
MI700C96065OtherBCBS
TXN7281OtherSTATE LICENSE
MIC20578OtherRAILROAD MEDICARE