1265469399 NPI number — DR. BRIAN A HOLTAN MD

Table of content: DR. BRIAN A HOLTAN MD (NPI 1265469399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265469399 NPI number — DR. BRIAN A HOLTAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLTAN
Provider First Name:
BRIAN
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1265469399
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
31003 N 118TH LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEORIA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85383-8240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-242-6958
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
31003 N 118TH LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEORIA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85383-8240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-242-6958
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2006

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: 2085R0202X , with the licence number:  3921A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0202X , with the licence number: 36220 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 83022243882901A002 . This is a "TRIWEST COLLEGE" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 83022243882935A002 . This is a "TRIWEST UINTA" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 103629700 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1265469399 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 179931 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 305941 . This is a "BCBS OF WY" identifier , issued by the state of ( WY ) . This identifiers is of the category "OTHER".
  • Identifier: 106059200 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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