Provider Demographics
NPI:1104805019
Name:HOLLIDAY, HEATH R (OD)
Entity type:Individual
Prefix:
First Name:HEATH
Middle Name:R
Last Name:HOLLIDAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:KS
Mailing Address - Zip Code:66801
Mailing Address - Country:US
Mailing Address - Phone:620-343-7120
Mailing Address - Fax:620-343-2038
Practice Address - Street 1:512 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:KS
Practice Address - Zip Code:66801
Practice Address - Country:US
Practice Address - Phone:620-343-7120
Practice Address - Fax:620-343-2038
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1685152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
V01893Medicare UPIN
KS651004Medicare ID - Type Unspecified