Healthcare Provider Details

I. General information

NPI: 1033420112
Provider Name (Legal Business Name): DANIEL KEVIN HOLT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

IV. Provider business mailing address

3635 VISTA AVE
SAINT LOUIS MO
63110-2539
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-5783
  • Fax: 314-268-5116
Mailing address:
  • Phone: 314-268-5783
  • Fax: 314-268-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2015009566
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: