Healthcare Provider Details

I. General information

NPI: 1164416764
Provider Name (Legal Business Name): DAVID GLENN HOLST MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

824 PINE ST
MOUNT SHASTA CA
96067-2137
US

IV. Provider business mailing address

PO BOX 339
MOUNT SHASTA CA
96067-0339
US

V. Phone/Fax

Practice location:
  • Phone: 530-926-4528
  • Fax: 530-926-5070
Mailing address:
  • Phone: 530-926-5613
  • Fax: 530-926-8798

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG76027
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberG76027
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: