Healthcare Provider Details

I. General information

NPI: 1134358997
Provider Name (Legal Business Name): JUSTIN ROBERT HOLLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 11/27/2023
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10122 E 10TH ST STE210
INDIANAPOLIS IN
46229-2664
US

IV. Provider business mailing address

6626 E 75TH ST SUITE 500
INDIANAPOLIS IN
46250-2890
US

V. Phone/Fax

Practice location:
  • Phone: 317-355-2230
  • Fax: 317-355-2305
Mailing address:
  • Phone: 317-355-2184
  • Fax: 317-355-2305

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number11015096A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01070715A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: