Provider Demographics
NPI:1720128259
Name:HOLT, JONATHAN A (DO)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:A
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 1:2817 W END AVE
Mailing Address - Street 2:436
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-1453
Mailing Address - Country:US
Mailing Address - Phone:650-450-8102
Mailing Address - Fax:
Practice Address - Street 1:1893 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60035-2628
Practice Address - Country:US
Practice Address - Phone:650-450-8102
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.162121207R00000X
TN2042207SG0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207SG0201XAllopathic & Osteopathic PhysiciansMedical GeneticsClinical Genetics (M.D.)
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX89800Medicaid
020A89800Medicare ID - Type Unspecified
CA00AX89800Medicaid