=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669456661
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK JAY HOLZBERG M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2005
-----------------------------------------------------
Last Update Date | 03/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 710 NEWNAN CROSSING BYPASS SUITE A
-----------------------------------------------------
City | NEWNAN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30263-2321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-251-5111
-----------------------------------------------------
Fax | 770-254-8680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7300 RANCH ROAD 2222, BUILDING 1, STE 200
-----------------------------------------------------
City | AUSTIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-628-0465
-----------------------------------------------------
Fax | 512-233-2711
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 029001
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207NS0135X
-----------------------------------------------------
Taxonomy Name | Procedural Dermatology Physician
-----------------------------------------------------
License Number | 029001
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------