Provider Demographics
NPI:1184674962
Name:HOLLOMON, MICHAEL G (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:G
Last Name:HOLLOMON
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 1:601 WEST MAPLE
Mailing Address - Street 2:SUITE 403
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-5374
Mailing Address - Country:US
Mailing Address - Phone:479-750-2742
Mailing Address - Fax:479-750-2742
Practice Address - Street 1:601 W MAPLE
Practice Address - Street 2:SUITE 403
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-5374
Practice Address - Country:US
Practice Address - Phone:479-750-2742
Practice Address - Fax:479-750-2742
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR25972084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR103605001Medicaid
C68530Medicare UPIN
AR103605001Medicaid