Provider Demographics
NPI:1588712913
Name:HOLLIFIELD, DAVID GLEN (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:GLEN
Last Name:HOLLIFIELD
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 1:2336 WISTERIA DRIVE
Mailing Address - Street 2:SUITE 430
Mailing Address - City:SHELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078
Mailing Address - Country:US
Mailing Address - Phone:770-982-4411
Mailing Address - Fax:770-982-3020
Practice Address - Street 1:2336 WISTERIA DRIVE
Practice Address - Street 2:SUITE 430
Practice Address - City:SHELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078
Practice Address - Country:US
Practice Address - Phone:770-982-4411
Practice Address - Fax:770-982-3020
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0404112081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F14199Medicare UPIN
GA25BRBRDMedicare ID - Type Unspecified