Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223D0004X | Dentist Anesthesiologist | 15567 | TX |
N | 207L00000X | Anesthesiologist | 15567 | TX |
NPI | 1336125384 |
---|---|
Provider Name | Dr. John Robert Holt |
First Address | Lubbock, TX 79407-2286 |
Second Address | Lubbock, TX 79407-2286 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/12/2005 |
Last Update Date | 19/11/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0902165 | (05) | TX |
75-2277547 | FEDERAL TAX ID (01) | TX |
K53H | BLUE CROSS BLUE SHIELD (01) | TX |
U41975 | (02) | TX |