1407293442 NPI number — JOHNATHAN MARTIN HOLLYFIELD MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407293442 NPI number — JOHNATHAN MARTIN HOLLYFIELD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLLYFIELD
Provider First Name:
JOHNATHAN
Provider Middle Name:
MARTIN
Provider Name Prefix Text:
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:
1407293442
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11025 RCA CENTER DR STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33410-4269
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-383-3820
Provider Business Mailing Address Fax Number:
855-369-2450

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
343 ELM ST STE 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-746-3400
Provider Business Practice Location Address Fax Number:
775-746-3411
Provider Enumeration Date:
05/31/2013

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: 207ZP0102X , with the licence number:  192214 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: 17859 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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