Provider Demographics
NPI:1619149903
Name:DAVID R HOLLIDAY OD
Entity Type:Organization
Organization Name:DAVID R HOLLIDAY OD
Other - Org Name:WAITKUS EYE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:HOLLIDAY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:304-253-8822
Mailing Address - Street 1:624 NEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-5344
Mailing Address - Country:US
Mailing Address - Phone:304-253-8822
Mailing Address - Fax:304-253-3012
Practice Address - Street 1:624 NEVILLE ST
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-5344
Practice Address - Country:US
Practice Address - Phone:304-253-8822
Practice Address - Fax:304-253-3012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-27
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0150018000Medicaid
WV0635260001Medicare NSC
WVWA0817431Medicare PIN
WV0150018000Medicaid