Provider Demographics
NPI:1215993712
Name:HOLTZ, S JEROME (MD)
Entity type:Individual
Prefix:DR
First Name:S
Middle Name:JEROME
Last Name:HOLTZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 BROUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3989
Mailing Address - Country:US
Mailing Address - Phone:973-743-1331
Mailing Address - Fax:973-743-6577
Practice Address - Street 1:108 BROUGHTON AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3989
Practice Address - Country:US
Practice Address - Phone:973-743-1331
Practice Address - Fax:973-743-6577
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA 28482207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1815709Medicaid
NJ460682CAHMedicare ID - Type Unspecified
NJ1815709Medicaid