MEDICARE: JOHN BLAKE HOLT M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician	ME58979	FL
2	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician	ME58979	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P01369815-INDIVIDUAL	OTHER	FL	RR MEDICARE
3	DV0492-GROUP	OTHER	FL	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	007WM	OTHER	FL	BLUE SHIELD FLORIDA
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932195385
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN BLAKE HOLT M.D.

Provider Business Mailing Address
First Line	:	1240 W GRANADA BLVD
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-5915
Country	:	US
Telephone Number	:	386-236-6854
Fax Number	:	386-263-2996

Provider Business Practice Location Address
First Line	:	1240 W GRANADA BLVD FL 2
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32174-5915
Country	:	US
Telephone Number	:	386-672-9503
Fax Number	:	386-672-0386

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	01/21/2025

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