Healthcare Provider Details

I. General information

NPI: 1376768440
Provider Name (Legal Business Name): KEVIN R. HOLBERT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 01/22/2024
Certification Date: 01/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 CORPORATE SQUARE BLVD
JACKSONVILLE FL
32216-1941
US

IV. Provider business mailing address

1900 CORPORATE SQUARE BLVD
JACKSONVILLE FL
32216-1941
US

V. Phone/Fax

Practice location:
  • Phone: 904-899-4500
  • Fax: 904-899-4538
Mailing address:
  • Phone: 904-899-4500
  • Fax: 904-899-4538

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberME117810
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number69866
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: