Provider Demographics
NPI:1932105483
Name:HOLY, MICHAEL A (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:HOLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1801 FAIRFIELD AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4457
Mailing Address - Country:US
Mailing Address - Phone:318-424-1617
Mailing Address - Fax:318-424-1610
Practice Address - Street 1:1801 FAIRFIELD AVE
Practice Address - Street 2:STE 101
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4457
Practice Address - Country:US
Practice Address - Phone:318-424-1617
Practice Address - Fax:318-424-1610
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA03517R207W00000X
TXD4157207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1142239Medicaid
LA5J447Medicare PIN
B60478Medicare UPIN
LA5J447BD28Medicare PIN
TX8F3087Medicare PIN