Provider Demographics
NPI:1851519813
Name:HOLMES, DEREK RYAN (DO)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:RYAN
Last Name:HOLMES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5352
Mailing Address - Fax:
Practice Address - Street 1:390 S MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151-1767
Practice Address - Country:US
Practice Address - Phone:540-484-4836
Practice Address - Fax:540-484-4837
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102204551207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK204825628OtherAETNA
OK200061280AMedicaid
OKOKA103607Medicare PIN
OK204825628OtherAETNA