Provider Demographics
NPI:1659453611
Name:SPOHN-GROSS, HOLLY (DPM)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:SPOHN-GROSS
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6425 LYNCH CANYON DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ISABELLA
Mailing Address - State:CA
Mailing Address - Zip Code:93240-9726
Mailing Address - Country:US
Mailing Address - Phone:760-379-8630
Mailing Address - Fax:760-379-7658
Practice Address - Street 1:6425 LYNCH CANYON DR
Practice Address - Street 2:
Practice Address - City:LAKE ISABELLA
Practice Address - State:CA
Practice Address - Zip Code:93240-9726
Practice Address - Country:US
Practice Address - Phone:760-379-8630
Practice Address - Fax:760-379-7658
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4349213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE4349OtherSTATE LICENSE
CA213E00000XOtherTAXONOMY
CAF67653Medicare UPIN
CA5865860001Medicare NSC
CA000E43490Medicare PIN