Provider Demographics
NPI:1477997369
Name:HOLADAY, CLINTON R
Entity Type:Individual
Prefix:
First Name:CLINTON
Middle Name:R
Last Name:HOLADAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 E MADISON ST STE 2D
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62701-3120
Mailing Address - Country:US
Mailing Address - Phone:217-508-5859
Mailing Address - Fax:
Practice Address - Street 1:319 E MADISON ST STE 2D
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62701-3120
Practice Address - Country:US
Practice Address - Phone:217-508-5859
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-22
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017039564207P00000X
IL036145002208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice