Healthcare Provider Details

I. General information

NPI: 1801281027
Provider Name (Legal Business Name): SCOTT HOLMES D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2015
Last Update Date: 10/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 N MCDOWELL BLVD
PETALUMA CA
94954
US

IV. Provider business mailing address

1179 N MCDOWELL BLVD
PETALUMA CA
94954-6559
US

V. Phone/Fax

Practice location:
  • Phone: 707-559-7500
  • Fax: 707-559-7620
Mailing address:
  • Phone: 707-559-7500
  • Fax: 707-559-7620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A17517
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: