Provider Demographics
NPI:1760454847
Name:HORN, WADE A (OD)
Entity Type:Individual
Prefix:
First Name:WADE
Middle Name:A
Last Name:HORN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 E MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47302-4857
Mailing Address - Country:US
Mailing Address - Phone:765-282-2020
Mailing Address - Fax:765-284-1150
Practice Address - Street 1:3303 E MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47302-4857
Practice Address - Country:US
Practice Address - Phone:765-282-2020
Practice Address - Fax:765-284-1150
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INT69248152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100134940BMedicaid
000000088411OtherANTHEM
000000088411OtherANTHEM
IN410041383Medicare PIN
IN142400AMedicare PIN