Provider Demographics
NPI:1588925655
Name:LONGSTREET, HOLLY (DO)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:LONGSTREET
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8558 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7032
Mailing Address - Country:US
Mailing Address - Phone:219-392-7084
Mailing Address - Fax:219-703-6854
Practice Address - Street 1:1354 S LAKE PARK AVE STE B
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-5964
Practice Address - Country:US
Practice Address - Phone:219-945-4495
Practice Address - Fax:219-703-6701
Is Sole Proprietor?:No
Enumeration Date:2012-06-05
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN02004654A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201299700Medicaid
IN201299700Medicaid
IN177280038Medicare PIN