Healthcare Provider Details

I. General information

NPI: 1700839891
Provider Name (Legal Business Name): JOHN ROBERT HOLTTUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 09/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 W BAY DR NW SUITE 214A
OLYMPIA WA
98502-4926
US

IV. Provider business mailing address

324 W BAY DR NW SUITE 214A
OLYMPIA WA
98502-4926
US

V. Phone/Fax

Practice location:
  • Phone: 360-464-9110
  • Fax: 360-350-5610
Mailing address:
  • Phone: 360-464-9110
  • Fax: 360-350-5610

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD00031823
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: