Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 213E00000X | Podiatrist | 003 | GA |
N | 222Z00000X | Podiatrist | 003 | GA |
N | 224P00000X | Prosthetist | 003 | GA |
NPI | 1477610475 |
---|---|
Provider Name | Mr. Russell David Holcomb |
First Address | Canton, GA 30115-7933 |
Second Address | Canton, GA 30115-7933 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/01/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7700620 | (05) | NC |