Provider Demographics
NPI:1669456661
Name:HOLZBERG, MARK JAY (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:JAY
Last Name:HOLZBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7300 RANCH ROAD 2222, BUILDING 1, STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730
Mailing Address - Country:US
Mailing Address - Phone:512-628-0465
Mailing Address - Fax:512-233-2711
Practice Address - Street 1:710 NEWNAN CROSSING BYPASS
Practice Address - Street 2:SUITE A
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-2321
Practice Address - Country:US
Practice Address - Phone:770-251-5111
Practice Address - Fax:770-254-8680
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA029001207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0306450OtherUHC
GA000310043IMedicaid
GA4118834OtherATENA NON-HMO
GA0403543006OtherCIGNA HMO
GA2034373OtherAETNA HMO
GA070012762OtherRAILROAD MEDICARE
GA0306450OtherUHC
GA07BBSFHMedicare ID - Type Unspecified