Provider Demographics
NPI:1578649554
Name:HOLTZ, GERALD BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:BRIAN
Last Name:HOLTZ
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 1:705 S SLEIGHT ST
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60540-6628
Mailing Address - Country:US
Mailing Address - Phone:630-903-4520
Mailing Address - Fax:
Practice Address - Street 1:705 S SLEIGHT ST
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-6628
Practice Address - Country:US
Practice Address - Phone:630-903-4520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-447662085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK02428OtherMPIN
ILD15286Medicare UPIN