Provider Demographics
NPI:1194708511
Name:HORNER, TIMOTHY DALE (OD)
Entity type:Individual
Prefix:DR
First Name:TIMOTHY
Middle Name:DALE
Last Name:HORNER
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 1:536 BULWER ST
Mailing Address - Street 2:PO BOX 158
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-1907
Mailing Address - Country:US
Mailing Address - Phone:740-574-4745
Mailing Address - Fax:740-574-5144
Practice Address - Street 1:536 BULWER ST
Practice Address - Street 2:
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694-1907
Practice Address - Country:US
Practice Address - Phone:740-574-4745
Practice Address - Fax:740-574-5144
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-21
Last Update Date:2010-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3321 T1247152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0417749Medicaid
OH0417749Medicaid
0172850001Medicare NSC
HOO471693Medicare PIN
C1 0471693Medicare PIN