Provider Demographics
NPI:1114928611
Name:HOLLER, JODY DALE (MD)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:DALE
Last Name:HOLLER
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2700 PROVIDENCE RD S
Practice Address - Street 2:STE 300
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-6313
Practice Address - Country:US
Practice Address - Phone:704-243-2254
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200200918207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891314CMedicaid
NC1114928611Medicaid
SCNC1048Medicaid
NC2018188DMedicare PIN
NCNC6307BMedicare PIN
NC2018188EMedicare PIN
SCNC1048Medicaid
NC1114928611Medicaid
NC2018188AMedicare PIN
H86994Medicare UPIN
NC2018188FMedicare PIN