Provider Demographics
NPI:1215195649
Name:HOLSTED, CARROLL EUGENE (MD)
Entity Type:Individual
Prefix:DR
First Name:CARROLL
Middle Name:EUGENE
Last Name:HOLSTED
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 1:3 WOODBRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BELLA VISTA
Mailing Address - State:AR
Mailing Address - Zip Code:72714-1927
Mailing Address - Country:US
Mailing Address - Phone:479-855-2160
Mailing Address - Fax:479-876-6312
Practice Address - Street 1:3 WOODBRIDGE DR
Practice Address - Street 2:
Practice Address - City:BELLA VISTA
Practice Address - State:AR
Practice Address - Zip Code:72714-1927
Practice Address - Country:US
Practice Address - Phone:479-855-2160
Practice Address - Fax:479-876-6312
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK8959207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine