Provider Demographics
NPI:1467418152
Name:PITRE, HOLLAND J (MD)
Entity Type:Individual
Prefix:MR
First Name:HOLLAND
Middle Name:J
Last Name:PITRE
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 1:1202 MISSION PARK DR
Mailing Address - Street 2:1202 MISSION PARK DR
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-3758
Mailing Address - Country:US
Mailing Address - Phone:601-415-6089
Mailing Address - Fax:601-636-6677
Practice Address - Street 1:1202 MISSION PARK DR
Practice Address - Street 2:1202 MISSION PARK DR
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-3758
Practice Address - Country:US
Practice Address - Phone:601-415-6089
Practice Address - Fax:601-636-6677
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-22
Last Update Date:2013-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12026207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1095303Medicaid
MS3021079461OtherPTAN
MSB65414Medicare UPIN
54551Medicare ID - Type Unspecified
LA1095303Medicaid