Provider Demographics
NPI:1124008263
Name:HOLCOMB, CHRISTIAN L (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:L
Last Name:HOLCOMB
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 1:8134A OSWEGO RD
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090
Mailing Address - Country:US
Mailing Address - Phone:315-409-4514
Mailing Address - Fax:315-409-4537
Practice Address - Street 1:8134A OSWEGO RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090
Practice Address - Country:US
Practice Address - Phone:315-409-4514
Practice Address - Fax:315-409-4537
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236483-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2723875Medicaid
NYI49801Medicare UPIN
NY2723875Medicaid
NYRB3520Medicare PIN