Provider Demographics
NPI:1972913135
Name:HORTON, NICHOLAS JOSEPH
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:HORTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 MONROE ST UNIT 103
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2771
Mailing Address - Country:US
Mailing Address - Phone:419-843-7996
Mailing Address - Fax:
Practice Address - Street 1:5700 MONROE ST UNIT 103
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2771
Practice Address - Country:US
Practice Address - Phone:419-843-7996
Practice Address - Fax:419-841-7704
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-28
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.138696207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program