Provider Demographics
NPI:1376570077
Name:HOLLAND, E CARLISLE (DO)
Entity type:Individual
Prefix:
First Name:E
Middle Name:CARLISLE
Last Name:HOLLAND
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 1:496 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-4211
Mailing Address - Country:US
Mailing Address - Phone:707-824-8764
Mailing Address - Fax:707-824-8766
Practice Address - Street 1:496 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-4211
Practice Address - Country:US
Practice Address - Phone:707-824-8764
Practice Address - Fax:707-824-8766
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6298208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE78079Medicare UPIN