Provider Demographics
NPI:1962557066
Name:HORNER, PAUL (OD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
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 1:613 N OAK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:SD
Mailing Address - Zip Code:57005-1573
Mailing Address - Country:US
Mailing Address - Phone:605-582-3737
Mailing Address - Fax:
Practice Address - Street 1:105 N SPLITROCK BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:SD
Practice Address - Zip Code:57005-1529
Practice Address - Country:US
Practice Address - Phone:605-582-2990
Practice Address - Fax:605-582-2991
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD535152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD4998511OtherBCBS BRANDON
MN5C470HOOtherBCBS BRANDON
SD9201702Medicaid
410031181OtherRAILROAD MCR
242530OtherMIDLANDS CHOICE
MN5C469HOOtherBCBS SIOUX FALLS
9202869-535.1OtherDAKOTA CARE SIOUX FALLS
20722OtherSIOUX VALLEY HLTH PLN
2202147OtherMEDICA BRANDON
SD9201700Medicaid
SD0004506OtherBCBS SIOUX FALLS
2202146OtherMEDICA SIOUX FALLS
MN5C470HOOtherBCBS BRANDON
SDS6148Medicare ID - Type UnspecifiedBRANDON
SD0004506OtherBCBS SIOUX FALLS