Provider Demographics
NPI:1942211792
Name:HORN, RUSSELL HAMILTON (OD)
Entity Type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:HAMILTON
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 1:303 BRUCE ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-3478
Mailing Address - Country:US
Mailing Address - Phone:530-841-2636
Mailing Address - Fax:530-841-2637
Practice Address - Street 1:303 BRUCE ST
Practice Address - Street 2:SUITE B
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3478
Practice Address - Country:US
Practice Address - Phone:530-841-2636
Practice Address - Fax:530-841-2637
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2513T152W00000X
CA13570T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR082938Medicaid
CADO053AOtherPTAN
OR082938Medicaid