Provider Demographics
NPI:1700839891
Name:HOLTTUM, JOHN ROBERT (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ROBERT
Last Name:HOLTTUM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:324 W BAY DR NW
Mailing Address - Street 2:SUITE 214A
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-4926
Mailing Address - Country:US
Mailing Address - Phone:360-464-9110
Mailing Address - Fax:360-350-5610
Practice Address - Street 1:324 W BAY DR NW
Practice Address - Street 2:SUITE 214A
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-4926
Practice Address - Country:US
Practice Address - Phone:360-464-9110
Practice Address - Fax:360-350-5610
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD000318232084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAF06336Medicare UPIN