Provider Demographics
NPI:1881629376
Name:HOLGUIN, THERESE ANN (MD)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:ANN
Last Name:HOLGUIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 N TURQUOISE DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-1383
Mailing Address - Country:US
Mailing Address - Phone:928-774-5074
Mailing Address - Fax:928-779-0884
Practice Address - Street 1:1490 N TURQUOISE DR
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1383
Practice Address - Country:US
Practice Address - Phone:928-774-5074
Practice Address - Fax:928-779-0884
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM88-191207N00000X
AZ19361207ND0101X, 207NS0135X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ295114Medicaid
AZ070002910OtherRXR MEDICARE
AZWCHQB-02Medicare ID - Type Unspecified
E-22713Medicare UPIN