Basic Information
| Provider Information | |||||||||
| NPI: | 1306894050 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLDIMAN | ||||||||
| FirstName: | DALE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 328 | ||||||||
| Address2: | |||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511020328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122795830 | ||||||||
| FaxNumber: | 7122795883 | ||||||||
| Practice Location | |||||||||
| Address1: | 624 JONES ST | ||||||||
| Address2: | STE 5400 | ||||||||
| City: | SIOUX CITY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 511051924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7122792510 | ||||||||
| FaxNumber: | 7122792519 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 10/17/2007 | ||||||||
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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 | 20689 | IA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100251443-00 | 05 | IA | MEDICAID | 7782140 | 05 | IA | MEDICAID | 3164657 | 05 | IA | MEDICAID | 36901 | 01 | IA | WELLMARK BCBS | OTHER |