Provider Demographics
NPI:1760462089
Name:HOLSTON, KIRK S (DPM)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:S
Last Name:HOLSTON
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 1:10332 POWER DR
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-4759
Mailing Address - Country:US
Mailing Address - Phone:317-846-0515
Mailing Address - Fax:
Practice Address - Street 1:3850 SHORE DR
Practice Address - Street 2:SUITE 301
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-5621
Practice Address - Country:US
Practice Address - Phone:317-297-3338
Practice Address - Fax:317-297-9997
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001328A208100000X
IN070000768A213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN0005497063OtherAETNA
IN000000364510OtherANTHEM BCBS
IN100121880Medicaid
P00284245OtherRR MCR
IN100121880AMedicaid
IN202158547OtherTRICARE
5392850001Medicare NSC
P00284245OtherRR MCR
IN210070CMedicare PIN
INU38614Medicare UPIN
IN100121880AMedicaid
5392850002Medicare NSC