Provider Demographics
NPI:1619194032
Name:HORNER, BRIAN J (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
Last Name:HORNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-1105
Mailing Address - Fax:239-343-1106
Practice Address - Street 1:13340 METRO PKWY STE 400
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966-4818
Practice Address - Country:US
Practice Address - Phone:239-343-1105
Practice Address - Fax:239-343-1106
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS12664207RC0200X
NC200800102207RP1001X
RIDO00595207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012796000Medicaid
NC5910603Medicaid
SCN0010AMedicaid