Basic Information
| Provider Information | |||||||||
| NPI: | 1629028873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HORTON | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 BODIN CIR | ||||||||
| Address2: | |||||||||
| City: | TRAVIS AFB | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945351809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074233330 | ||||||||
| FaxNumber: | 7074237382 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 BODIN CIR | ||||||||
| Address2: | |||||||||
| City: | TRAVIS AFB | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945351809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7074233330 | ||||||||
| FaxNumber: | 7074237382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 05/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 8545 | NV | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 002018755 | 05 | NV | MEDICAID |