Provider Demographics
NPI:1700843992
Name:HOLT, ROBERT GARY (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:GARY
Last Name:HOLT
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:PO BOX 1547
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-0361
Mailing Address - Country:US
Mailing Address - Phone:541-673-4303
Mailing Address - Fax:541-440-9739
Practice Address - Street 1:1813 W HARVARD AVE
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2752
Practice Address - Country:US
Practice Address - Phone:541-673-4303
Practice Address - Fax:541-440-9739
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2009-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA346042085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR278529Medicaid
A44787Medicare UPIN
R136247Medicare PIN