Provider Demographics
NPI:1356304588
Name:HOLT, KENNETH A (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:A
Last Name:HOLT
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 1:3320 EXECUTIVE DR
Mailing Address - Street 2:STE 222
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7445
Mailing Address - Country:US
Mailing Address - Phone:919-877-1100
Mailing Address - Fax:
Practice Address - Street 1:3320 EXECUTIVE DR
Practice Address - Street 2:STE 222
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7445
Practice Address - Country:US
Practice Address - Phone:919-877-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9901643207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCH14449Medicare UPIN
NC1356304588Medicare NSC