Healthcare Provider Details

I. General information

NPI: 1376630723
Provider Name (Legal Business Name): IRENE HOLECEK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5321 EVERTS ST
SAN DIEGO CA
92109-1234
US

IV. Provider business mailing address

5321 EVERTS ST
SAN DIEGO CA
92109-1234
US

V. Phone/Fax

Practice location:
  • Phone: 858-488-4550
  • Fax: 619-444-1595
Mailing address:
  • Phone: 858-488-4550
  • Fax: 619-444-1595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA40301
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: