Healthcare Provider Details

I. General information

NPI: 1508857194
Provider Name (Legal Business Name): ROBERT G HOLZHAUER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 08/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 FARMINGTON AVE
BRISTOL CT
06010-3931
US

IV. Provider business mailing address

PO BOX 1120
BRISTOL CT
06011-1120
US

V. Phone/Fax

Practice location:
  • Phone: 860-314-6046
  • Fax: 860-314-6047
Mailing address:
  • Phone: 860-585-3945
  • Fax: 860-585-3907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number000236
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: