Provider Demographics
NPI:1003893215
Name:HOLTHAUS, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:HOLTHAUS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17809
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32245-7809
Mailing Address - Country:US
Mailing Address - Phone:904-723-0015
Mailing Address - Fax:904-338-0951
Practice Address - Street 1:1361 13TH AVE S
Practice Address - Street 2:STE 150
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3233
Practice Address - Country:US
Practice Address - Phone:904-242-7177
Practice Address - Fax:904-242-7133
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME43785174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15832OtherBCBS
FL110241847OtherRAILROAD MEDICARE
FLD52751Medicare UPIN
FL15832TMedicare PIN