Provider Demographics
NPI:1740217207
Name:HOLTHOUSE, MARK E (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:HOLTHOUSE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3104 PONTE MORINO DR STE 110
Mailing Address - Street 2:
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-8282
Mailing Address - Country:US
Mailing Address - Phone:530-676-1003
Mailing Address - Fax:530-676-7350
Practice Address - Street 1:3104 PONTE MORINO DRIVE
Practice Address - Street 2:STE 110
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682
Practice Address - Country:US
Practice Address - Phone:530-676-1003
Practice Address - Fax:530-676-7350
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2008-12-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG757170207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0070790Medicaid
CAGR0070790Medicaid
CA00G757170Medicare ID - Type Unspecified