Provider Demographics
NPI:1376630723
Name:HOLECEK, IRENE (MD)
Entity Type:Individual
Prefix:DR
First Name:IRENE
Middle Name:
Last Name:HOLECEK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5321 EVERTS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-1234
Mailing Address - Country:US
Mailing Address - Phone:858-488-4550
Mailing Address - Fax:619-444-1595
Practice Address - Street 1:5321 EVERTS ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-1234
Practice Address - Country:US
Practice Address - Phone:858-488-4550
Practice Address - Fax:619-444-1595
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40301208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A403010Medicaid