Healthcare Provider Details

I. General information

NPI: 1548234388
Provider Name (Legal Business Name): LAWRENCE HOLDER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 09/03/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W 8TH ST UFJP RADIOLOGY DEPT.
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

PO BOX 44008 UFJP PROVIDER ENROLLMENT
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-4229
  • Fax: 904-244-3382
Mailing address:
  • Phone: 904-244-3660
  • Fax: 904-244-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME80894
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License NumberME80894
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: