Provider Demographics
NPI:1336247899
Name:HOLLOWAY, WALTER R (MD)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:R
Last Name:HOLLOWAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:181 N KENTUCKY ST STE 200
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-2089
Mailing Address - Country:US
Mailing Address - Phone:417-255-8337
Mailing Address - Fax:417-255-2720
Practice Address - Street 1:181 N KENTUCKY ST STE 200
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2089
Practice Address - Country:US
Practice Address - Phone:417-255-8337
Practice Address - Fax:417-255-2720
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110894208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO100049OtherBC/BS
AR130543001Medicaid
MO506131408Medicaid
MO208541805Medicaid
MO100049OtherBC/BS
AR130543001Medicaid