Provider Demographics
NPI:1821083718
Name:HOLDER, DONOVAN O (MD)
Entity Type:Individual
Prefix:
First Name:DONOVAN
Middle Name:O
Last Name:HOLDER
Suffix:
Gender:M
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:PO BOX 2001
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4501
Mailing Address - Country:US
Mailing Address - Phone:315-449-0513
Mailing Address - Fax:315-445-2936
Practice Address - Street 1:200 CLIFTON SPRINGS PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:CLIFTON SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:14432-1036
Practice Address - Country:US
Practice Address - Phone:315-462-5060
Practice Address - Fax:315-462-5062
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165662208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
00146905Medicare PIN
NYRA1616Medicare PIN
E15585Medicare UPIN