Provider Demographics
NPI:1982625976
Name:HOLLOWAY, GARY P (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:P
Last Name:HOLLOWAY
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 1:50 N PERRY ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-2217
Mailing Address - Country:US
Mailing Address - Phone:248-338-5516
Mailing Address - Fax:248-338-5547
Practice Address - Street 1:46 W SHADBOLT ST
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-3170
Practice Address - Country:US
Practice Address - Phone:248-814-9300
Practice Address - Fax:248-814-9304
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101012531207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3402566-11Medicaid
MI0M20610007Medicare ID - Type Unspecified
MI3402566-11Medicaid