Provider Demographics
NPI:1164404844
Name:HOLTZCLAW, PRISCILLA WILCOX (MD)
Entity Type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:WILCOX
Last Name:HOLTZCLAW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:3400 SALTERBECK CT
Practice Address - Street 2:STE 100
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7118
Practice Address - Country:US
Practice Address - Phone:843-971-3361
Practice Address - Fax:843-971-8492
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC24134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00775520OtherRAILROAD MEDICARE ID - EFFECTIVE 5/11/2009
SC241349Medicaid
SCAA03289223Medicare PIN
SC241349Medicaid
SCI32382Medicare UPIN