Provider Demographics
NPI:1881709210
Name:HOLLEMON, MARK R (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:R
Last Name:HOLLEMON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:PO BOX 23200
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97281-3200
Mailing Address - Country:US
Mailing Address - Phone:503-224-0817
Mailing Address - Fax:503-224-0839
Practice Address - Street 1:2330 NW FLANDERS ST
Practice Address - Street 2:SUITE 104
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-3442
Practice Address - Country:US
Practice Address - Phone:503-224-0817
Practice Address - Fax:503-224-0839
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORDO18822207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
R113774Medicare PIN