Provider Demographics
NPI:1245430800
Name:DWAN, HOLLY JANE (OD)
Entity Type:Individual
Prefix:MRS
First Name:HOLLY
Middle Name:JANE
Last Name:DWAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:891 WESTMINSTER ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4020
Mailing Address - Country:US
Mailing Address - Phone:401-331-7850
Mailing Address - Fax:401-331-7850
Practice Address - Street 1:891 WESTMINSTER ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4020
Practice Address - Country:US
Practice Address - Phone:401-331-7850
Practice Address - Fax:401-274-4739
Is Sole Proprietor?:No
Enumeration Date:2007-07-23
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIODTG00586152W00000X
NH0683152W00000X
MA4145152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1245430800Medicaid
NHJARE5678Medicare ID - Type Unspecified