Provider Demographics
NPI:1962498089
Name:HOLT, MARK A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:A
Last Name:HOLT
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:PO BOX 228
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-0228
Mailing Address - Country:US
Mailing Address - Phone:740-380-4181
Mailing Address - Fax:740-385-0865
Practice Address - Street 1:819 STATE ROUTE 664 N
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-8540
Practice Address - Country:US
Practice Address - Phone:740-380-8140
Practice Address - Fax:740-380-8150
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35057635207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0929777Medicaid
OH0929777Medicaid
OHNE4042591Medicare PIN