Provider Demographics
NPI:1417021213
Name:HOLLETT, DAVID STANLEY
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:STANLEY
Last Name:HOLLETT
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 1:1500 WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48309-1858
Mailing Address - Country:US
Mailing Address - Phone:248-651-8156
Mailing Address - Fax:248-650-3083
Practice Address - Street 1:1500 WALTON BLVD
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48309-1858
Practice Address - Country:US
Practice Address - Phone:248-651-8156
Practice Address - Fax:248-650-3083
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301042584207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2111896Medicaid
MI2111896Medicaid
MI06302806011Medicare ID - Type Unspecified