Provider Demographics
NPI:1396816989
Name:ADDISON, HOLLAND M (MD)
Entity Type:Individual
Prefix:
First Name:HOLLAND
Middle Name:M
Last Name:ADDISON
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 1:4045 EASTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-6442
Mailing Address - Country:US
Mailing Address - Phone:601-352-2273
Mailing Address - Fax:
Practice Address - Street 1:4045 EASTWOOD DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-6442
Practice Address - Country:US
Practice Address - Phone:601-352-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08984207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00116199Medicaid
MS00116199Medicaid
MS110001024Medicare PIN