Provider Demographics
NPI:1477524783
Name:HOLT, JOHN PLUMMER (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PLUMMER
Last Name:HOLT
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 1:540 VISTA DEL LAGO LN
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-5340
Mailing Address - Country:US
Mailing Address - Phone:919-664-2867
Mailing Address - Fax:
Practice Address - Street 1:2600 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-1502
Practice Address - Country:US
Practice Address - Phone:919-881-9999
Practice Address - Fax:919-881-9998
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31724174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8942977Medicaid
NC207348EMedicare ID - Type Unspecified
NC8942977Medicaid