Provider Demographics
NPI:1356349245
Name:PROVOST, HOLLY C (MD)
Entity type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:C
Last Name:PROVOST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:3975 I 49 S SERVICE RD
Mailing Address - Street 2:SUITE 205A
Mailing Address - City:OPELOUSAS
Mailing Address - State:LA
Mailing Address - Zip Code:70570-0775
Mailing Address - Country:US
Mailing Address - Phone:337-942-2323
Mailing Address - Fax:337-942-2626
Practice Address - Street 1:3975 I 49 S SERVICE RD
Practice Address - Street 2:SUITE 205A
Practice Address - City:OPELOUSAS
Practice Address - State:LA
Practice Address - Zip Code:70570-0775
Practice Address - Country:US
Practice Address - Phone:337-942-2323
Practice Address - Fax:337-942-2626
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA024378207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA160059334OtherRAILROAD MEDICARE PROV #
AL7352418OtherAETNA PROVIDER ID NUMBER
LA1571831Medicaid
LA4E439CC55Medicare UPIN
LA1571831Medicaid