Provider Demographics
NPI:1588821763
Name:LAWDER, HOLLY (MD)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:
Last Name:LAWDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 S ALMA SCHOOL RD
Mailing Address - Street 2:STE 14000
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-2096
Mailing Address - Country:US
Mailing Address - Phone:480-456-9000
Mailing Address - Fax:
Practice Address - Street 1:1201 S ALMA SCHOOL RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-2008
Practice Address - Country:US
Practice Address - Phone:480-545-8119
Practice Address - Fax:480-892-6805
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ370742085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZP00624720OtherRAILROAD MEDICARE
AZ336662Medicaid
AZZ165257Medicare PIN
AZP00624720OtherRAILROAD MEDICARE
AZZ122187Medicare PIN