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 1:880 GOLF VIEW DR STE 101
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8496
Mailing Address - Country:US
Mailing Address - Phone:541-779-3797
Mailing Address - Fax:
Practice Address - Street 1:880 GOLF VIEW DR STE 101
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8496
Practice Address - Country:US
Practice Address - Phone:541-779-3797
Practice Address - Fax:541-842-2194
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2024-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13570T152W00000X
OR2513ATI152W00000X
OR2513T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADO053AOtherPTAN
OR082938Medicaid
OR082938Medicaid