Provider Demographics
NPI:1285657916
Name:HOLLAND, CHARLES MITCHELL (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MITCHELL
Last Name:HOLLAND
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 1:509 BROOKMAN DR
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2326
Mailing Address - Country:US
Mailing Address - Phone:601-823-5204
Mailing Address - Fax:601-833-1224
Practice Address - Street 1:509 BROOKMAN DR
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2326
Practice Address - Country:US
Practice Address - Phone:601-823-5204
Practice Address - Fax:601-833-1224
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11043208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115067Medicaid
MS370000428Medicare ID - Type Unspecified
MS00115067Medicaid