Provider Demographics
NPI:1417914326
Name:HOLDER, LARRY W (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:W
Last Name:HOLDER
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:PO BOX 19636
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9636
Mailing Address - Country:US
Mailing Address - Phone:217-545-0182
Mailing Address - Fax:217-545-4735
Practice Address - Street 1:751 N RUTLEDGE ST
Practice Address - Street 2:STE 1100
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4968
Practice Address - Country:US
Practice Address - Phone:217-545-0182
Practice Address - Fax:217-545-4735
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036076848207R00000X, 207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036076848Medicaid
ILC43041Medicare UPIN
IL256510156Medicare PIN
IL036076848Medicaid