Healthcare Provider Details

I. General information

NPI: 1538145578
Provider Name (Legal Business Name): DAVID LESLIE HOLTZCLAW M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 27TH ST
VERO BEACH FL
32960-3383
US

IV. Provider business mailing address

223 3RD AVE
MELBOURNE BEACH FL
32951-2315
US

V. Phone/Fax

Practice location:
  • Phone: 772-794-7415
  • Fax:
Mailing address:
  • Phone: 321-952-0083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License NumberME0059437
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: