Provider Demographics
NPI:1245231844
Name:HOLBROOK, TODD R (MD)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:R
Last Name:HOLBROOK
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 1:619 DALTON ST
Mailing Address - Street 2:
Mailing Address - City:EMMAUS
Mailing Address - State:PA
Mailing Address - Zip Code:18049-3031
Mailing Address - Country:US
Mailing Address - Phone:610-628-8200
Mailing Address - Fax:610-965-6595
Practice Address - Street 1:619 DALTON ST
Practice Address - Street 2:
Practice Address - City:EMMAUS
Practice Address - State:PA
Practice Address - Zip Code:18049-3031
Practice Address - Country:US
Practice Address - Phone:610-628-8200
Practice Address - Fax:610-965-6595
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD063546L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001711286004Medicaid
PA001711286004Medicaid
004948Medicare ID - Type Unspecified