Provider Demographics
NPI:1588720544
Name:HOLMES, TODD GUNNAR (MD)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:GUNNAR
Last Name:HOLMES
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 1:1320 BISHOP RANDALL DR
Mailing Address - Street 2:
Mailing Address - City:LANDER
Mailing Address - State:WY
Mailing Address - Zip Code:82520-3939
Mailing Address - Country:US
Mailing Address - Phone:307-857-3488
Mailing Address - Fax:307-857-5215
Practice Address - Street 1:1320 BISHOP RANDALL DR
Practice Address - Street 2:
Practice Address - City:LANDER
Practice Address - State:WY
Practice Address - Zip Code:82520-3939
Practice Address - Country:US
Practice Address - Phone:307-857-3488
Practice Address - Fax:307-857-5215
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY9749A208100000X
MN28937208100000X
SC85487208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNF24422Medicare UPIN
MN23-00178OtherMEDICA
MN50G74HOOtherBLUE CROSS
MN120555OtherUCARE
MN250013908OtherRAILROAD MEDICARE
MN32427220Medicaid
MN139076800OtherACS
MNF24422Medicare UPIN