Provider Demographics
NPI:1023054434
Name:HOLLOWAY, WILLIS JR (MD)
Entity type:Individual
Prefix:
First Name:WILLIS
Middle Name:
Last Name:HOLLOWAY
Suffix:JR
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 1:6613 N MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-1423
Mailing Address - Country:US
Mailing Address - Phone:405-603-8450
Mailing Address - Fax:405-603-8455
Practice Address - Street 1:6613 N MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-1423
Practice Address - Country:US
Practice Address - Phone:405-603-8450
Practice Address - Fax:405-603-8455
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK152562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100046080AMedicaid
OK100046080AMedicaid
OK247317102Medicare ID - Type Unspecified