1124028097 NPI number — DR. KARMEN M HOLDINGHAUSEN OD

Table of content: DR. KARMEN M HOLDINGHAUSEN OD (NPI 1124028097)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124028097 NPI number — DR. KARMEN M HOLDINGHAUSEN OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLDINGHAUSEN
Provider First Name:
KARMEN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

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:
1124028097
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2010 BREMO RD STE 128A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHMOND
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23226-2444
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-969-0392
Provider Business Mailing Address Fax Number:
434-455-7172

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1825 GRAVES MILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOREST
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24551-3967
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
434-385-5600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/21/2005

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: 152W00000X , with the licence number:  2528 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 0618003082 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03051719 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4092572 . This is a "BCBS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3946305 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 191619722 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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