=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982695375
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TODD K HOLTZ MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2005
-----------------------------------------------------
Last Update Date | 09/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4230 BAY CITY RD
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48642-6014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-839-0750
-----------------------------------------------------
Fax | 989-839-9037
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4230 BAY CITY RD
-----------------------------------------------------
City | MIDLAND
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48642-6014
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-839-0750
-----------------------------------------------------
Fax | 989-839-9037
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | TH053390
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------