Provider Demographics
NPI:1588622260
Name:HOLDERMAN, DENNIS RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:RUSSELL
Last Name:HOLDERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DENNIS
Other - Middle Name:RUSSELL
Other - Last Name:HOLDERMAN II
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6722 STATE ROUTE 132
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:OH
Mailing Address - Zip Code:45122-9249
Mailing Address - Country:US
Mailing Address - Phone:513-924-8233
Mailing Address - Fax:513-924-8244
Practice Address - Street 1:6722 STATE ROUTE 132
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:OH
Practice Address - Zip Code:45122-9249
Practice Address - Country:US
Practice Address - Phone:513-924-8233
Practice Address - Fax:513-924-8244
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35083293207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000390305OtherANTHEM
OH2433585Medicaid
H96366Medicare UPIN
OH7316322Medicare ID - Type Unspecified