Provider Demographics
NPI:1265469399
Name:HOLTAN, BRIAN A (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:A
Last Name:HOLTAN
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 1:31003 N 118TH LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-8240
Mailing Address - Country:US
Mailing Address - Phone:623-242-6958
Mailing Address - Fax:
Practice Address - Street 1:31003 N 118TH LN
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85383-8240
Practice Address - Country:US
Practice Address - Phone:623-242-6958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY3921A2085R0202X
AZ362202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY83022243882901A002OtherTRIWEST COLLEGE
WY83022243882935A002OtherTRIWEST UINTA
WY103629700Medicaid
UT1265469399Medicaid
AZ179931Medicaid
WY305941OtherBCBS OF WY
WY83022243882935A002OtherTRIWEST UINTA
WY83022243882901A002OtherTRIWEST COLLEGE
AZ179931Medicaid
A73153Medicare UPIN
AZZ133445Medicare PIN
WYW24430Medicare PIN
300018672Medicare PIN