Healthcare Provider Details

I. General information

NPI: 1295802130
Provider Name (Legal Business Name): ROGER V. HOLMES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 VANDEVER AVE
SAN DIEGO CA
92120-3315
US

IV. Provider business mailing address

393 E WALNUT ST 3RD FLOOR PHR SYSTEMS
PASADENA CA
91188-0001
US

V. Phone/Fax

Practice location:
  • Phone: 619-528-5000
  • Fax:
Mailing address:
  • Phone: 626-405-3640
  • Fax: 626-405-6768

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG32518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: