=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578560777
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CLINTON DOUGLAS HOLDER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2005
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4604 29TH ST E
-----------------------------------------------------
City | PALMETTO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34221-9793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-845-4572
-----------------------------------------------------
Fax | 941-845-4572
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4604 29TH ST E
-----------------------------------------------------
City | PALMETTO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34221-9793
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-845-4572
-----------------------------------------------------
Fax | 941-845-4572
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RI0200X
-----------------------------------------------------
Taxonomy Name | Infectious Disease Physician
-----------------------------------------------------
License Number | 40558
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------