Provider Demographics
NPI:1891771317
Name:HOLTEN, KEITH B (MD)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:B
Last Name:HOLTEN
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 1:825 W LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:45177-2118
Mailing Address - Country:US
Mailing Address - Phone:937-383-3402
Mailing Address - Fax:937-383-0610
Practice Address - Street 1:825 W LOCUST ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:OH
Practice Address - Zip Code:45177-2118
Practice Address - Country:US
Practice Address - Phone:937-383-3402
Practice Address - Fax:937-383-0610
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.047577207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0528889Medicaid
A15689Medicare UPIN
OHHO7362841Medicare PIN