Provider Demographics
NPI:1063584324
Name:HOLLOWAY, REGINA LORREN (MD)
Entity type:Individual
Prefix:DR
First Name:REGINA
Middle Name:LORREN
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 CARROLLTON STREET
Mailing Address - Street 2:
Mailing Address - City:BREMEN
Mailing Address - State:GA
Mailing Address - Zip Code:30110
Mailing Address - Country:US
Mailing Address - Phone:770-537-1960
Mailing Address - Fax:770-537-1901
Practice Address - Street 1:308 CARROLLTON STREET
Practice Address - Street 2:
Practice Address - City:BREMEN
Practice Address - State:GA
Practice Address - Zip Code:30110
Practice Address - Country:US
Practice Address - Phone:770-537-1960
Practice Address - Fax:770-537-1901
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA034852207Q00000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA142710464AOtherGBHC
GA00478552HMedicaid
GA021201960AOtherCAID PAYEE
GA08BDLCTMedicare ID - Type Unspecified
GA08BBRSDMedicare ID - Type Unspecified
F17566Medicare UPIN