1821195777 NPI number — DAVID HOLLOWAY M.D.

Table of content: DAVID HOLLOWAY M.D. (NPI 1821195777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821195777 NPI number — DAVID HOLLOWAY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLLOWAY
Provider First Name:
DAVID
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1821195777
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 14097
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST ALLIS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53214-0097
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-544-6486
Provider Business Mailing Address Fax Number:
262-544-6377

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2717 N GRANDVIEW BLVD STE 303
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAUKESHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53188-1660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-544-6486
Provider Business Practice Location Address Fax Number:
262-544-6377
Provider Enumeration Date:
09/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  27991-020 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 31699800 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".