Provider Demographics
NPI:1649228032
Name:HOLTERMAN, AI-XUAN L (MD)
Entity Type:Individual
Prefix:
First Name:AI-XUAN
Middle Name:L
Last Name:HOLTERMAN
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 1:3926 NEW VISION DR
Mailing Address - Street 2:BLDG H
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1712
Mailing Address - Country:US
Mailing Address - Phone:260-266-8213
Mailing Address - Fax:260-458-5658
Practice Address - Street 1:1725 W HARRISON ST
Practice Address - Street 2:SUITE 818
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3841
Practice Address - Country:US
Practice Address - Phone:312-942-5397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010572532086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF16996Medicare UPIN
ILL91510Medicare ID - Type Unspecified