MEDICARE: DR. OLAYINKA OMOWUNMI HOLT 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	207R00000X	Internal Medicine Physician	P1765	TX
2	208M00000X	Hospitalist Physician	P1765	TX
3	207RN0300X	Nephrology Physician	P1765	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	8ED520	OTHER	TX	BC/BS

General Provider Information

NPI Number	:	1871876011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OLAYINKA OMOWUNMI HOLT MD

Provider Business Mailing Address
First Line	:	1405 JACAMAN RD STE 102
Second Line	:
City	:	LAREDO
State	:	TX
Zip	:	78041-6225
Country	:	US
Telephone Number	:	956-568-9657
Fax Number	:	956-568-9659

Provider Business Practice Location Address
First Line	:	1405 JACAMAN RD STE 102
Second Line	:
City	:	LAREDO
State	:	TX
Zip	:	78041-6225
Country	:	US
Telephone Number	:	956-568-9657
Fax Number	:	956-568-9659

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

Provider Enumeration Date	:	09/23/2011
Last Update Date	:	09/10/2019

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