Provider Demographics
NPI:1104811488
Name:HOLM, MARILYN KAY (OD)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:KAY
Last Name:HOLM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 CAREFREE PL
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-9141
Mailing Address - Country:US
Mailing Address - Phone:907-220-1962
Mailing Address - Fax:
Practice Address - Street 1:2800 CORNERSTONE DR STE A6
Practice Address - Street 2:
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-8157
Practice Address - Country:US
Practice Address - Phone:970-731-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1550152W00000X
AK334152W00000X
CO3846152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100346290DMedicaid
2062367OtherFIRST HEALTH
KS398580OtherFIRSTGUARD
KS651065OtherBCBS
KS13089OtherPHS
MH0458706OtherDEA
2062367OtherFIRST HEALTH
KS651068Medicare ID - Type Unspecified
KS651065OtherBCBS