Provider Demographics
NPI:1689772519
Name:HOLT, CHARLES E (DO)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:HOLT
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 1:280 NORTH MAIN
Mailing Address - Street 2:PO BOX 88
Mailing Address - City:TOOELE
Mailing Address - State:UT
Mailing Address - Zip Code:84074-0088
Mailing Address - Country:US
Mailing Address - Phone:435-882-8610
Mailing Address - Fax:435-882-0186
Practice Address - Street 1:280 N MAIN ST
Practice Address - Street 2:
Practice Address - City:TOOELE
Practice Address - State:UT
Practice Address - Zip Code:84074-1650
Practice Address - Country:US
Practice Address - Phone:435-882-8610
Practice Address - Fax:435-882-0186
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1788691204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTD07745Medicare UPIN
UT000004293Medicare ID - Type Unspecified