Provider Demographics
NPI:1073565487
Name:HOLMES, DOUGLAS L (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:L
Last Name:HOLMES
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 1:307 S JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2908
Mailing Address - Country:US
Mailing Address - Phone:307-237-3937
Mailing Address - Fax:307-237-0670
Practice Address - Street 1:307 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2908
Practice Address - Country:US
Practice Address - Phone:307-237-3937
Practice Address - Fax:307-237-0670
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30384174400000X
WY8868A207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01303841Medicaid
807061Medicare PIN
CO01303841Medicaid