Provider Demographics
NPI:1194718536
Name:HOLLER, ALTAGRACIA LOPEZ (OD)
Entity type:Individual
Prefix:
First Name:ALTAGRACIA
Middle Name:LOPEZ
Last Name:HOLLER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ALTAGRACIA
Other - Middle Name:
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7100 SIX FORKS RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-6156
Mailing Address - Country:US
Mailing Address - Phone:919-847-0187
Mailing Address - Fax:919-676-2231
Practice Address - Street 1:2042 KILDAIRE FARM RD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-6614
Practice Address - Country:US
Practice Address - Phone:919-851-9995
Practice Address - Fax:919-859-4172
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1730152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0923AOtherBLUECROSS
NC890923AMedicaid
NC410048142OtherRAILROAD MEDICARE
NC890923AMedicaid