MEDICARE: DR. JODIE SUSAN HOLLOWAY 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	173000000X	Legal Medicine	019557	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992921688
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JODIE SUSAN HOLLOWAY M.D.

Provider Business Mailing Address
First Line	:	112 RANDOM OAKS LN
Second Line	:
City	:	MANDEVILLE
State	:	LA
Zip	:	70448-4565
Country	:	US
Telephone Number	:	985-674-0988
Fax Number	:	985-674-5308

Provider Business Practice Location Address
First Line	:	112 RANDOM OAKS LN
Second Line	:
City	:	MANDEVILLE
State	:	LA
Zip	:	70448-4565
Country	:	US
Telephone Number	:	985-674-0988
Fax Number	:	985-674-5308

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

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	07/08/2007

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Directions to “ DR. JODIE SUSAN HOLLOWAY M.D.” Practice Location

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