Healthcare Provider Details

I. General information

NPI: 1881654150
Provider Name (Legal Business Name): RALPH EDWARD HOLSWORTH JR. D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 03/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

373 E 10TH AVE
SPRINGFIELD CO
81073-1622
US

IV. Provider business mailing address

15300 QUANDARY PEAK RD
PINE CO
80470-9135
US

V. Phone/Fax

Practice location:
  • Phone: 719-523-6628
  • Fax: 719-523-4290
Mailing address:
  • Phone: 970-560-0011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37599
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP60185754
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: