Provider Demographics
NPI:1790818359
Name:HOLLIWAY, BRONDWYN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRONDWYN
Middle Name:
Last Name:HOLLIWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3824 HEARNE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4328
Mailing Address - Country:US
Mailing Address - Phone:318-635-8606
Mailing Address - Fax:318-635-1265
Practice Address - Street 1:3824 HEARNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4328
Practice Address - Country:US
Practice Address - Phone:318-635-8606
Practice Address - Fax:318-635-1265
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA021100208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1966207Medicaid
LA1449423OtherGROUP NUMBER
LA5R787Medicare ID - Type Unspecified
LA1966207Medicaid