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NPI Code Detail

MEDICARE: DAVID LESLIE HOLTZCLAW M.D.

MEDICARE: DAVID LESLIE HOLTZCLAW M.D.
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
1204C00000XSports Medicine (Neuromusculoskeletal Medicine) PhysicianME0059437FL

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1ME0058437OTHERFLMEDICAL LICENSE NUMBER

General Provider Information

NPI Number : 1538145578
Entity Type Code : Individual
Provider Name (Legal Business Name) : DAVID LESLIE HOLTZCLAW M.D.
Provider Business Mailing Address
First Line : 223 3RD AVE
Second Line :
City : MELBOURNE BEACH
State : FL
Zip : 32951-2315
Country : US
Telephone Number : 321-952-0083
Fax Number :
Provider Business Practice Location Address
First Line : 1900 27TH ST
Second Line :
City : VERO BEACH
State : FL
Zip : 32960-3383
Country : US
Telephone Number : 772-794-7415
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/21/2005
Last Update Date : 07/09/2007

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