Healthcare Provider Details

I. General information

NPI: 1649228032
Provider Name (Legal Business Name): AI-XUAN L HOLTERMAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 W HARRISON ST SUITE 818
CHICAGO IL
60612-3841
US

IV. Provider business mailing address

3926 NEW VISION DR BLDG H
FORT WAYNE IN
46845-1712
US

V. Phone/Fax

Practice location:
  • Phone: 312-942-5397
  • Fax:
Mailing address:
  • Phone: 260-266-8213
  • Fax: 260-458-5658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License Number01057253
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: