Provider Demographics
NPI:1326123555
Name:HOLM, ALFRED JOHN (MD)
Entity Type:Individual
Prefix:
First Name:ALFRED
Middle Name:JOHN
Last Name:HOLM
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 1569
Mailing Address - Street 2:
Mailing Address - City:OCEAN SHORES
Mailing Address - State:WA
Mailing Address - Zip Code:98569-1569
Mailing Address - Country:US
Mailing Address - Phone:360-289-4151
Mailing Address - Fax:360-289-4693
Practice Address - Street 1:597 POINT BROWN AVE NW
Practice Address - Street 2:
Practice Address - City:OCEAN SHORES
Practice Address - State:WA
Practice Address - Zip Code:98569
Practice Address - Country:US
Practice Address - Phone:360-289-4151
Practice Address - Fax:360-289-4693
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042371207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1118736Medicaid
WAGAB40027Medicare ID - Type Unspecified
H28634Medicare UPIN