Basic Information
| Provider Information | |||||||||
| NPI: | 1285684415 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOROWITZ | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | LENARD | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3701 12TH ST N | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202583090 | ||||||||
| FaxNumber: | 3202583095 | ||||||||
| Practice Location | |||||||||
| Address1: | 3701 12TH ST N | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | SAINT CLOUD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 563032255 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3202583090 | ||||||||
| FaxNumber: | 3202583095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 11/20/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD00029475 | WA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 101525 | 01 | WA | L&I ID# | OTHER | 242719001 | 01 | WA | GROUP HEALTH ID# | OTHER | 8198309 | 01 | WA | CRIME VICTIMS OF WA | OTHER | 1093921 | 05 | WA | MEDICAID | 141447000 | 01 | WA | US DEPT OF LABOR | OTHER | HO8211 | 01 | WA | REGENCE BLUE SHIELD OF WA | OTHER |