Provider Demographics
NPI:1538145578
Name:HOLTZCLAW, DAVID LESLIE (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:LESLIE
Last Name:HOLTZCLAW
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 1:223 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-2315
Mailing Address - Country:US
Mailing Address - Phone:321-952-0083
Mailing Address - Fax:
Practice Address - Street 1:1900 27TH ST
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-3383
Practice Address - Country:US
Practice Address - Phone:772-794-7415
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0059437204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0058437OtherMEDICAL LICENSE NUMBER
FLME0058437OtherMEDICAL LICENSE NUMBER