Provider Demographics
NPI:1417196098
Name:HOLT, MARTIN C (PA)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:C
Last Name:HOLT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7439 LA PALMA AVE # 120
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-2655
Mailing Address - Country:US
Mailing Address - Phone:714-441-0411
Mailing Address - Fax:714-441-1824
Practice Address - Street 1:901 W ORANGETHORPE AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-2826
Practice Address - Country:US
Practice Address - Phone:714-441-0411
Practice Address - Fax:714-441-1824
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-05
Last Update Date:2009-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13479208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13479OtherPA CALIFORNIA LICENSE