Provider Demographics
NPI:1386671832
Name:HOLMES, KYLE DEAN (MD)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:DEAN
Last Name:HOLMES
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 1:2613 CARAVAGGIO PL
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-7659
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NORTHBAY MEDICAL CENTER - FAIRFIELD
Practice Address - Street 2:1200 B GALE WILSON BLVD
Practice Address - City:FAIRFEILD
Practice Address - State:CA
Practice Address - Zip Code:94533
Practice Address - Country:US
Practice Address - Phone:707-429-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77374207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G773741Medicaid
CA00G773742Medicare UPIN
CAE38386Medicare UPIN