Provider Demographics
NPI:1326003385
Name:HOLTHUSEN, GREGORY GRANT (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:GRANT
Last Name:HOLTHUSEN
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:PO BOX 25626
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27114-5626
Mailing Address - Country:US
Mailing Address - Phone:336-768-1270
Mailing Address - Fax:336-765-6375
Practice Address - Street 1:170 KIMEL PARK DR
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6946
Practice Address - Country:US
Practice Address - Phone:336-768-1270
Practice Address - Fax:336-765-6375
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2011-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17871207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89-43461Medicaid
NC89-43461Medicaid
NC207351AMedicare ID - Type UnspecifiedMEDICARE NUMBER