Provider Demographics
NPI:1245368794
Name:HOLDER, JOHN M (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:HOLDER
Suffix:
Gender:M
Credentials:DO
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 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:602-866-8603
Mailing Address - Fax:602-866-2413
Practice Address - Street 1:720 E THUNDERBIRD RD
Practice Address - Street 2:STE 3
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85022-5396
Practice Address - Country:US
Practice Address - Phone:602-866-8603
Practice Address - Fax:602-866-2413
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAZ1437207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZE84585Medicare UPIN
AZZ184836Medicare PIN
AZZWCMBR01Medicare ID - Type Unspecified