Provider Demographics
NPI:1851300032
Name:HOLTOM, PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:
Last Name:HOLTOM
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:LAC USC MEDICAL CENTER
Mailing Address - Street 2:1200 N. STATE SE. ROOM C5E100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033
Mailing Address - Country:US
Mailing Address - Phone:323-409-6645
Mailing Address - Fax:323-441-8250
Practice Address - Street 1:1520 SAN PABLO ST
Practice Address - Street 2:SUITE 1000
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5310
Practice Address - Country:US
Practice Address - Phone:323-442-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG044895207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G448950197OtherCAL OPTIMA
CAW18762OtherGROUP MEDICARE
CA00G448950Medicaid
CA440000831OtherRAILROAD MEDICARE
CACE1617OtherGROUP RAILROAD MEDICARE
CA1902846306OtherGROUP NPI
CAGR0016910OtherGROUP MEDICAID PIN
CAW11675OtherGROUP MEDICARE PIN
CAZZZ50018ZOtherGROUP BLUE SHIELD
CA00G448950OtherBLUE SHIELD
CA06E2774OtherGROUP CHAMPUS
CAGR0100430OtherGROUP MEDICAL
CA1356390009OtherGROUP NPI
CA00G448950Medicaid
CAWG44895AMedicare PIN