Provider Demographics
NPI:1629276084
Name:HENRY T HORRILLENO MD PA
Entity Type:Organization
Organization Name:HENRY T HORRILLENO MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:T
Authorized Official - Last Name:HORRILLENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-225-4200
Mailing Address - Street 1:1800 W 1ST ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-3133
Mailing Address - Country:US
Mailing Address - Phone:580-225-4200
Mailing Address - Fax:580-225-4201
Practice Address - Street 1:1800 W 1ST ST
Practice Address - Street 2:SUITE 108
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-3133
Practice Address - Country:US
Practice Address - Phone:580-225-4200
Practice Address - Fax:580-225-4201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-06
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25632208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200115760AMedicaid
F24712Medicare UPIN
OK900522604Medicare PIN