Provider Demographics
NPI:1194055699
Name:HORNER, MARY (MD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:HORNER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:SOCKOLOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5340 ELVAS AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-2385
Mailing Address - Country:US
Mailing Address - Phone:916-739-1505
Mailing Address - Fax:
Practice Address - Street 1:3900 JUNIUS ST STE 145
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1616
Practice Address - Country:US
Practice Address - Phone:972-386-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-05
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXTRAINING207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program