Provider Demographics
NPI:1124339544
Name:HOLMES, HEATHER REBECCA (MD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:REBECCA
Last Name:HOLMES
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 1:2564 NW EDENBOWER BLVD, SUITE 126
Mailing Address - Street 2:
Mailing Address - City:ROSENBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471
Mailing Address - Country:US
Mailing Address - Phone:541-672-7718
Mailing Address - Fax:
Practice Address - Street 1:2564 NW EDENBOWER BLVD, SUITE 126
Practice Address - Street 2:
Practice Address - City:ROSENBURG
Practice Address - State:OR
Practice Address - Zip Code:97471
Practice Address - Country:US
Practice Address - Phone:541-672-7718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10037211207Q00000X
TXP5381207Q00000X
ORMD166592207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500674045Medicaid
ORR177245Medicare Oscar/Certification