Provider Demographics
NPI:1477638005
Name:HOLT, CHARLES REED (DO)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:REED
Last Name:HOLT
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 1:2026 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52803-2911
Mailing Address - Country:US
Mailing Address - Phone:515-537-0326
Mailing Address - Fax:
Practice Address - Street 1:2026 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52803-2911
Practice Address - Country:US
Practice Address - Phone:515-537-0326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02981207P00000X
OK4350207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1477638005Medicaid
IA6131490Medicaid
IA1477638005OtherBLUE SHIELD
IA1477638005OtherBLUE SHIELD
IA52523Medicare ID - Type Unspecified
IA6131490Medicaid