Provider Demographics
NPI:1275628380
Name:HOLLADAY, KENNETH DAVID (MD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:DAVID
Last Name:HOLLADAY
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 1:9830 NE CASCADES PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-6832
Mailing Address - Country:US
Mailing Address - Phone:503-239-8101
Mailing Address - Fax:
Practice Address - Street 1:9830 NE CASCADES PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-6832
Practice Address - Country:US
Practice Address - Phone:503-239-8101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1567922084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
20861000OtherAETNA
AKMD24422Medicaid
AKMH9931Medicaid
AK421545189OtherBC
239264OtherCOMPSYCH
239264OtherCOMPSYCH
AKMH9931Medicaid