Healthcare Provider Details

I. General information

NPI: 1710939145
Provider Name (Legal Business Name): RICHARD PAUL HOLLSTROM,JR DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 11/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1555 DOCTORS DR STE 106
LAGRANGE GA
30240-4139
US

IV. Provider business mailing address

1555 DOCTORS DR STE 106
LAGRANGE GA
30240-4139
US

V. Phone/Fax

Practice location:
  • Phone: 706-845-9370
  • Fax: 706-845-9371
Mailing address:
  • Phone: 706-845-9370
  • Fax: 706-845-9371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPOD000988
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: