Provider Demographics
NPI:1568492999
Name:HOLLOWAY, JEFFREY LYNN (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:LYNN
Last Name:HOLLOWAY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 HARRIS PKWY STE 290
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76132-4127
Mailing Address - Country:US
Mailing Address - Phone:817-433-5880
Mailing Address - Fax:817-292-3627
Practice Address - Street 1:6100 HARRIS PKWY STE 290
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-4127
Practice Address - Country:US
Practice Address - Phone:817-433-5880
Practice Address - Fax:817-292-3627
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003012712208600000X
TXQ2298208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1568492999Medicaid
MOP00735208OtherRR MEDICARE
KS200612550AMedicaid
MO1568492999Medicaid