Provider Demographics
NPI:1811655764
Name:OVERHOLTZER, ISAAC DERYL
Entity type:Individual
Prefix:MR
First Name:ISAAC
Middle Name:DERYL
Last Name:OVERHOLTZER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:679 FM 2808 # 7
Mailing Address - Street 2:
Mailing Address - City:KEMPNER
Mailing Address - State:TX
Mailing Address - Zip Code:76539-5744
Mailing Address - Country:US
Mailing Address - Phone:254-577-0681
Mailing Address - Fax:
Practice Address - Street 1:36065 SANTA FE AVE
Practice Address - Street 2:
Practice Address - City:FORT HOOD
Practice Address - State:TX
Practice Address - Zip Code:76544-5060
Practice Address - Country:US
Practice Address - Phone:254-553-3147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10966491-3101164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse