MEDICARE: MARK JOHN HOLLAND MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	91 65	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	91-65	OTHER	NM	NEW MEXICO MEDICAL BOARD LICENSE NUMBER

General Provider Information

NPI Number	:	1346400181
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK JOHN HOLLAND MD

Provider Business Mailing Address
First Line	:	2301 SAN PEDRO DR NE
Second Line	:	SUITE B
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-4119
Country	:	US
Telephone Number	:	505-232-6818
Fax Number	:

Provider Business Practice Location Address
First Line	:	2301 SAN PEDRO DR NE
Second Line	:	SUITE B
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-4119
Country	:	US
Telephone Number	:	505-232-6818
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2008
Last Update Date	:	11/12/2012

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