1205828910 NPI number — DR. DAVID G HOLZWORTH D.O.

Table of content: DR. DAVID G HOLZWORTH D.O. (NPI 1205828910)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205828910 NPI number — DR. DAVID G HOLZWORTH D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLZWORTH
Provider First Name:
DAVID
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
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:
1205828910
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14600 KING RD
Provider Second Line Business Mailing Address:
SUITE D
Provider Business Mailing Address City Name:
RIVERVIEW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48193-7952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-479-7310
Provider Business Mailing Address Fax Number:
734-479-7307

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14600 KING RD
Provider Second Line Business Practice Location Address:
SUITE D
Provider Business Practice Location Address City Name:
RIVERVIEW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48193-7952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-479-7310
Provider Business Practice Location Address Fax Number:
734-479-7307
Provider Enumeration Date:
08/18/2005

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: 207YX0905X , with the licence number:  5101006598 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P46665 . This is a "BLUE CARE NETWORK" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 1302187 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1758239605 . This is a "BLUE CROSS MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: C5092 . This is a "MCARE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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