Provider Demographics
NPI:1144241704
Name:HOLLAND, CHARLES DALE JR (MD)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:DALE
Last Name:HOLLAND
Suffix:JR
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 1:205 SE HOWARD AVE
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-2204
Mailing Address - Country:US
Mailing Address - Phone:918-333-0474
Mailing Address - Fax:918-333-5125
Practice Address - Street 1:205 SE HOWARD AVE
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2204
Practice Address - Country:US
Practice Address - Phone:918-333-0474
Practice Address - Fax:918-333-5125
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15492207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100089920AMedicaid
KS100130650CMedicaid
OK247427410Medicare PIN
F05551Medicare UPIN
OK040008095Medicare PIN