Provider Demographics
NPI:1063851517
Name:HOLDER, REBECCA ELIZABETH (DO)
Entity Type:Individual
Prefix:DR
First Name:REBECCA
Middle Name:ELIZABETH
Last Name:HOLDER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:ELIZABETH
Other - Last Name:HOLDER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:1920 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-1764
Mailing Address - Country:US
Mailing Address - Phone:719-225-9120
Mailing Address - Fax:719-553-1904
Practice Address - Street 1:1207 PUEBLO BOULEVARD WAY
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-2175
Practice Address - Country:US
Practice Address - Phone:719-542-0032
Practice Address - Fax:719-553-1904
Is Sole Proprietor?:No
Enumeration Date:2013-06-18
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0057350207RI0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO65155050Medicaid
CO550855YK2DMedicare PIN