Provider Demographics
NPI:1407889330
Name:HOLT, WOLCOTT SMITHSON
Entity Type:Individual
Prefix:
First Name:WOLCOTT
Middle Name:SMITHSON
Last Name:HOLT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-8364
Mailing Address - Fax:
Practice Address - Street 1:400 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1951
Practice Address - Country:US
Practice Address - Phone:218-786-8364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN226112084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31322200Medicaid
MN185883100Medicaid
D75757Medicare UPIN
MN185883100Medicaid