=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023102886
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL T HOLLEY MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2006
-----------------------------------------------------
Last Update Date | 05/02/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2065 SOUTH KANNER HIGHWAY
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34994
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-286-0677
-----------------------------------------------------
Fax | 772-286-6720
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2065 SOUTH KANNER HIGHWAY
-----------------------------------------------------
City | STUART
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34994
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-286-0677
-----------------------------------------------------
Fax | 772-286-6720
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | ME73391
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------