Healthcare Provider Details

I. General information

NPI: 1477520666
Provider Name (Legal Business Name): MR. THOMAS WILLIAM HOLDER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MEDICAL DEPARTMENT, 2000 JERRY ST PE HWY
PASCAGOULA MS
39568-7003
US

IV. Provider business mailing address

2147 FEATHERWOOD DR W
ATLANTIC BEACH FL
32233-6922
US

V. Phone/Fax

Practice location:
  • Phone: 228-935-2388
  • Fax:
Mailing address:
  • Phone: 904-270-7968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: