Provider Demographics
NPI:1922085190
Name:HORN, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
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 1:3945 SAN JOSE PARK DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32217-4612
Mailing Address - Country:US
Mailing Address - Phone:904-731-3530
Mailing Address - Fax:904-737-1548
Practice Address - Street 1:3945 SAN JOSE PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32217-4612
Practice Address - Country:US
Practice Address - Phone:904-731-3530
Practice Address - Fax:904-737-1548
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME22378208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D53119Medicare UPIN