Healthcare Provider Details

I. General information

NPI: 1659720944
Provider Name (Legal Business Name): JEREMY MICHAEL HORAK D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 06/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 4TH ST MS 6211
LUBBOCK TX
79430-6211
US

IV. Provider business mailing address

3601 4TH ST MS 6211
LUBBOCK TX
79430-6211
US

V. Phone/Fax

Practice location:
  • Phone: 806-743-2978
  • Fax: 806-743-1599
Mailing address:
  • Phone: 806-743-2978
  • Fax: 806-743-1599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberBP10056159
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: