Provider Demographics
NPI:1417961103
Name:HOLLAND, THEODORE F III (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:F
Last Name:HOLLAND
Suffix:III
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 1:679 E COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-1049
Mailing Address - Country:US
Mailing Address - Phone:317-890-2000
Mailing Address - Fax:317-859-4269
Practice Address - Street 1:8240 NAAB ROAD
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1986
Practice Address - Country:US
Practice Address - Phone:317-876-2330
Practice Address - Fax:317-876-2320
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026261A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100065120Medicaid
IN000000351008OtherANTHEM PROVIDER NUMBER
INP00205108OtherMEDICARE RAILROAD
IN100194370OtherMEDICAID GROUP NUMBER
IN677730NNMedicare PIN
IN100065120Medicaid
IN000000351008OtherANTHEM PROVIDER NUMBER