Provider Demographics
NPI:1861687501
Name:HOLTZMAN, JERRY (PA)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:HOLTZMAN
Suffix:
Gender:M
Credentials:PA
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 673671
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-3671
Mailing Address - Country:US
Mailing Address - Phone:810-720-5715
Mailing Address - Fax:810-732-0891
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-423-2454
Practice Address - Fax:248-423-2576
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2009-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001709363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP35120139Medicare PIN
MI0N33470Medicare PIN