Provider Demographics
NPI:1578560777
Name:HOLDER, CLINTON DOUGLAS (MD)
Entity Type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:DOUGLAS
Last Name:HOLDER
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 1:4604 29TH ST E
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:FL
Mailing Address - Zip Code:34221-9793
Mailing Address - Country:US
Mailing Address - Phone:941-845-4572
Mailing Address - Fax:941-845-4572
Practice Address - Street 1:4604 29TH ST E
Practice Address - Street 2:
Practice Address - City:PALMETTO
Practice Address - State:FL
Practice Address - Zip Code:34221-9793
Practice Address - Country:US
Practice Address - Phone:941-845-4572
Practice Address - Fax:941-845-4572
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL40558207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0040558OtherWORKERS' COMPENSATION
FL9205221OtherUNITEDHEALTHCARE
FL042203700Medicaid
FL5600211OtherGHI
FL30588OtherBLUE CROSS/BLUE SHIELD
FL440003237OtherRAILROAD MEDICARE
PA923014OtherBLUE CROSS/BLUE SHIELD
PA923014OtherBLUE CROSS/BLUE SHIELD
FLME0040558OtherWORKERS' COMPENSATION
FL9205221OtherUNITEDHEALTHCARE