Provider Demographics
NPI:1649201252
Name:HOLBROOK, MARC L (MD)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:L
Last Name:HOLBROOK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:3490 VINCE RD
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-8830
Mailing Address - Country:US
Mailing Address - Phone:859-621-0763
Mailing Address - Fax:859-263-7441
Practice Address - Street 1:217 S 3RD ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1823
Practice Address - Country:US
Practice Address - Phone:859-621-0763
Practice Address - Fax:859-263-7441
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY18602207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64-186026Medicaid
KYC65641Medicare UPIN