Provider Demographics
NPI:1528124195
Name:HORNER, KYLE LELAND (MD)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:LELAND
Last Name:HORNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 S. MAIN ROAD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OR
Mailing Address - Zip Code:97355
Mailing Address - Country:US
Mailing Address - Phone:541-258-7546
Mailing Address - Fax:541-570-1744
Practice Address - Street 1:2500 S. MAIN ROAD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OR
Practice Address - Zip Code:97355
Practice Address - Country:US
Practice Address - Phone:541-258-7546
Practice Address - Fax:541-570-1744
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD153145207N00000X
OH094794207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500633817Medicaid