1679069819 NPI number — JOHN HAYDEN HOLTZCLAW AU.D.

Table of content: JOHN HAYDEN HOLTZCLAW AU.D. (NPI 1679069819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679069819 NPI number — JOHN HAYDEN HOLTZCLAW AU.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLTZCLAW
Provider First Name:
JOHN
Provider Middle Name:
HAYDEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AU.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:
1679069819
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3705 MEDICAL PKWY
Provider Second Line Business Mailing Address:
STE 320
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78705-1023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-454-0392
Provider Business Mailing Address Fax Number:
512-454-1233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1340 WONDER WORLD DR STE 4301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN MARCOS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78666-7695
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-547-8369
Provider Business Practice Location Address Fax Number:
512-738-8396
Provider Enumeration Date:
07/10/2018

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: 231H00000X , with the licence number:  80958 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 80958 . This is a "TEXAS AUDIOLOGIST LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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