Provider Demographics
NPI:1124023668
Name:HOLLADAY, ROBERT C (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:C
Last Name:HOLLADAY
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 1:850 OLIVE ST
Mailing Address - Street 2:STE A
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2162
Mailing Address - Country:US
Mailing Address - Phone:318-222-3662
Mailing Address - Fax:318-222-0034
Practice Address - Street 1:850 OLIVE ST
Practice Address - Street 2:STE A
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2162
Practice Address - Country:US
Practice Address - Phone:318-222-3662
Practice Address - Fax:318-222-0034
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA020136207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1987115Medicaid
LAF77411Medicare UPIN
LA5U277C022Medicare ID - Type Unspecified