Provider Demographics
NPI:1033133384
Name:HOLDEN, LARRY DWIGHT (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:DWIGHT
Last Name:HOLDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DWIGHT
Other - Middle Name:
Other - Last Name:HOLDEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, FAPA, INC
Mailing Address - Street 1:3 E GOLDEN EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87506-8223
Mailing Address - Country:US
Mailing Address - Phone:505-988-7476
Mailing Address - Fax:505-986-6453
Practice Address - Street 1:3 E GOLDEN EAGLE RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87506-8223
Practice Address - Country:US
Practice Address - Phone:505-988-7476
Practice Address - Fax:505-986-6453
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-08052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry