Healthcare Provider Details

I. General information

NPI: 1043496300
Provider Name (Legal Business Name): BRIAN LEE HOLT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 MARTIN LUTHER KING AVE NE SUITE 301
ALBUQUERQUE NM
87102-3661
US

IV. Provider business mailing address

5400 GIBSON BLVD SE
ALBUQUERQUE NM
87108-4729
US

V. Phone/Fax

Practice location:
  • Phone: 505-262-7281
  • Fax: 505-262-7622
Mailing address:
  • Phone: 505-262-7960
  • Fax: 505-232-1368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD2014-0842
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: