Provider Demographics
NPI:1710939145
Name:HOLLSTROM,JR, RICHARD PAUL (DPM)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:PAUL
Last Name:HOLLSTROM,JR
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 DOCTORS DR
Mailing Address - Street 2:STE 106
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4139
Mailing Address - Country:US
Mailing Address - Phone:706-845-9370
Mailing Address - Fax:706-845-9371
Practice Address - Street 1:1555 DOCTORS DR
Practice Address - Street 2:STE 106
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4139
Practice Address - Country:US
Practice Address - Phone:706-845-9370
Practice Address - Fax:706-845-9371
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPOD000988213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA723086380AMedicaid
GA723086380AMedicaid
GAU91404Medicare UPIN