Provider Demographics
NPI:1679675854
Name:HOLLAND, JOHN R (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:HOLLAND
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3043 NE 28TH STREET
Mailing Address - Street 2:
Mailing Address - City:LINCOLN CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97367-9540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3043 NE 28TH STREET
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-9540
Practice Address - Country:US
Practice Address - Phone:541-996-7118
Practice Address - Fax:541-996-7378
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1948207P00000X
NC200400681207P00000X
ORDO172963207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891362YMedicaid
VA1679675854Medicaid
NC891362YMedicaid
TN103I934039Medicare PIN