Provider Demographics
NPI:1831127224
Name:HOLTAN, JOHN MARK (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MARK
Last Name:HOLTAN
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 1:5713 STRATHMOOR DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-7093
Mailing Address - Country:US
Mailing Address - Phone:815-398-4545
Mailing Address - Fax:815-399-7705
Practice Address - Street 1:5713 STRATHMOOR DR
Practice Address - Street 2:SUITE 1
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-7093
Practice Address - Country:US
Practice Address - Phone:815-398-4545
Practice Address - Fax:815-399-7705
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL801580Medicare ID - Type UnspecifiedMEDICARE GROUP #
ILL29699Medicare ID - Type Unspecified
ILCC5050Medicare ID - Type UnspecifiedRR MEDICARE GROUP #
ILL37360Medicare ID - Type Unspecified
ILD15586Medicare UPIN