Healthcare Provider Details

I. General information

NPI: 1932195385
Provider Name (Legal Business Name): JOHN BLAKE HOLT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2005
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 W GRANADA BLVD FL 2
ORMOND BEACH FL
32174-5915
US

IV. Provider business mailing address

1240 W GRANADA BLVD
ORMOND BEACH FL
32174-5915
US

V. Phone/Fax

Practice location:
  • Phone: 386-672-9503
  • Fax: 386-672-0386
Mailing address:
  • Phone: 386-236-6854
  • Fax: 386-263-2996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME58979
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberME58979
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: