Provider Demographics
NPI:1851321277
Name:HOLLADAY, JACK T (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:T
Last Name:HOLLADAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JACK
Other - Middle Name:T
Other - Last Name:HOLLADAY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6602 MAPLERIDGE
Mailing Address - Street 2:200
Mailing Address - City:BELLAIRE
Mailing Address - State:TX
Mailing Address - Zip Code:77401
Mailing Address - Country:US
Mailing Address - Phone:713-668-7337
Mailing Address - Fax:713-668-7336
Practice Address - Street 1:6802 MAPLERIDGE ST
Practice Address - Street 2:200
Practice Address - City:BELLAIRE
Practice Address - State:TX
Practice Address - Zip Code:77401-3943
Practice Address - Country:US
Practice Address - Phone:713-668-7337
Practice Address - Fax:713-668-7336
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE2621174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC17024Medicare UPIN