Healthcare Provider Details

I. General information

NPI: 1790723443
Provider Name (Legal Business Name): IAN DENNIS HOLGADO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: I. DENNIS HOLGADO DO

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 W DEVON DR SUITE 100
EXTON PA
19341-3062
US

IV. Provider business mailing address

412 CREAMERY WAY SUITE 400
EXTON PA
19341-2551
US

V. Phone/Fax

Practice location:
  • Phone: 610-321-0200
  • Fax: 610-594-2625
Mailing address:
  • Phone: 610-594-7590
  • Fax: 610-594-2625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS012508
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier102434521
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: