Provider Demographics
NPI:1891820353
Name:HOLDER, STACEY (MD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HOLDER
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 1:5016 GILMER RD
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75604-9666
Mailing Address - Country:US
Mailing Address - Phone:903-553-0035
Mailing Address - Fax:903-553-0065
Practice Address - Street 1:5016 GILMER RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75604-9666
Practice Address - Country:US
Practice Address - Phone:903-553-0035
Practice Address - Fax:903-553-0065
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6764207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine