Provider Demographics
NPI:1710114434
Name:HORTON, JIMMIE ROGERS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JIMMIE
Middle Name:ROGERS
Last Name:HORTON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1475
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-1475
Mailing Address - Country:US
Mailing Address - Phone:515-643-0833
Mailing Address - Fax:515-643-0933
Practice Address - Street 1:1350 DES MOINES ST
Practice Address - Street 2:SUITE 110
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-5507
Practice Address - Country:US
Practice Address - Phone:515-643-0833
Practice Address - Fax:515-643-0933
Is Sole Proprietor?:No
Enumeration Date:2009-06-20
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IA40546207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1710114434Medicaid