Provider Demographics
NPI:1952054587
Name:HOLT, GIOVANNI L
Entity Type:Individual
Prefix:
First Name:GIOVANNI
Middle Name:L
Last Name:HOLT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5072 N 25TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-5643
Mailing Address - Country:US
Mailing Address - Phone:414-349-2133
Mailing Address - Fax:
Practice Address - Street 1:5072 N 25TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-5643
Practice Address - Country:US
Practice Address - Phone:414-349-2133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIH4302929204104172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver