Basic Information
| Provider Information | |||||||||
| NPI: | 1003844259 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLMES | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | MATTHEW | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 465 SAINT MICHAELS DR | ||||||||
| Address2: | SUITE 118 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059885120 | ||||||||
| FaxNumber: | 5059821812 | ||||||||
| Practice Location | |||||||||
| Address1: | 465 SAINT MICHAELS DR | ||||||||
| Address2: | SUITE 118 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875057670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059885120 | ||||||||
| FaxNumber: | 5059821812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ND0900X | 78-183 | NM | X | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207N00000X | 78-183 | NM | X | Allopathic & Osteopathic Physicians | Dermatology | 207NS0135X | 78-183 | NM | X | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology | 207NP0225X | 78-183 | NM | X | Allopathic & Osteopathic Physicians | Dermatology | Pediatric Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 11038668 | 01 | NM | CAQH-UNITED | OTHER | 17187 | 01 | NM | PRESBYTERIAN | OTHER | 24604 | 05 | NM | MEDICAID |