Provider Demographics
NPI:1225041825
Name:HOLTKAMP, DIEDRICH K (MD)
Entity type:Individual
Prefix:
First Name:DIEDRICH
Middle Name:K
Last Name:HOLTKAMP
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 1:541 BAY RIDGE PARKWAY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209
Mailing Address - Country:US
Mailing Address - Phone:718-748-6451
Mailing Address - Fax:718-921-4534
Practice Address - Street 1:541 BAY RIDGE PARKWAY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209
Practice Address - Country:US
Practice Address - Phone:718-748-6451
Practice Address - Fax:718-921-4534
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1288892086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00396474Medicaid
B18565Medicare UPIN
NY69A051Medicare ID - Type Unspecified