Provider Demographics
NPI:1821024720
Name:HOLDER, BLAIR T (MD)
Entity Type:Individual
Prefix:
First Name:BLAIR
Middle Name:T
Last Name:HOLDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:300 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 205
Mailing Address - City:DOVER
Mailing Address - State:OH
Mailing Address - Zip Code:44622-2073
Mailing Address - Country:US
Mailing Address - Phone:330-364-4600
Mailing Address - Fax:330-364-3338
Practice Address - Street 1:300 MEDICAL PARK DR
Practice Address - Street 2:SUITE 205
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622-2073
Practice Address - Country:US
Practice Address - Phone:330-364-4600
Practice Address - Fax:330-364-3338
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH55408207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0667569Medicaid
OH9305541Medicare ID - Type Unspecified
OH0667569Medicaid