Basic Information
| Provider Information | |||||||||
| NPI: | 1104907450 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLT | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | BARKALOW | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2030 W MOUNTAIN VIEW AVENUE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805013178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037761532 | ||||||||
| FaxNumber: | 3037763109 | ||||||||
| Practice Location | |||||||||
| Address1: | 2030 W MOUNTAIN VIEW AVENUE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | LONGMONT | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805013178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3037761532 | ||||||||
| FaxNumber: | 3037763109 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 19986 | CO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04005930 | 05 | CO | MEDICAID |