Provider Demographics
NPI:1104894047
Name:HOLT, KEN V (DO)
Entity type:Individual
Prefix:DR
First Name:KEN
Middle Name:V
Last Name:HOLT
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:KENNY
Other - Middle Name:V
Other - Last Name:HOLT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:125 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3919
Mailing Address - Country:US
Mailing Address - Phone:307-206-1330
Mailing Address - Fax:307-206-1331
Practice Address - Street 1:125 WYOMING ST
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3919
Practice Address - Country:US
Practice Address - Phone:307-206-1330
Practice Address - Fax:307-206-1331
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005020340207V00000X
WY13534A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOI136086Medicare UPIN
MO787E011Medicare ID - Type Unspecified