Provider Demographics
NPI:1164160156
Name:HOLODAK, JODIE TUTT (MD)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:TUTT
Last Name:HOLODAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 23RD AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-6070
Mailing Address - Country:US
Mailing Address - Phone:970-810-2815
Mailing Address - Fax:
Practice Address - Street 1:1600 23RD AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-6070
Practice Address - Country:US
Practice Address - Phone:970-810-2815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-20
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0071667207Q00000X
COTL.0009368390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program