Provider Demographics
NPI:1568432730
Name:HOLUB, MICHAEL LEE (OD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LEE
Last Name:HOLUB
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 W AVENUE K
Mailing Address - Street 2:SUITE A
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-6502
Mailing Address - Country:US
Mailing Address - Phone:661-942-8437
Mailing Address - Fax:661-940-1959
Practice Address - Street 1:1745 W AVENUE K
Practice Address - Street 2:SUITE A
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-6502
Practice Address - Country:US
Practice Address - Phone:661-942-8437
Practice Address - Fax:661-940-1959
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT6250TPA152W00000X, 152WC0802X
CAOPT6250T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZ40293ZOtherB/C B/S GROUP IDENTIFIER
CA2673OtherDAVIS VISION PROVIDER NUM
CASD00625000OtherB/C B/S IDENTIFIER
CA6517OtherMESC PROVIDER NUMBER
CAZZ40293ZOtherB/C B/S GROUP IDENTIFIER
CAZZ40293ZOtherB/C B/S GROUP IDENTIFIER
CASD00625000OtherB/C B/S IDENTIFIER
CA2673OtherDAVIS VISION PROVIDER NUM