Basic Information
| Provider Information | |||||||||
| NPI: | 1609138486 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HOLCOMB | ||||||||
| FirstName: | TIMOTHY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246400 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20208 ST HWY 155 S | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757625600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9038256222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2012 | ||||||||
| LastUpdateDate: | 10/31/2015 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | P7464 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 75-2616977-029 | 01 | TX | TRICARE | OTHER | 8FE338 | 01 | TX | BCBS | OTHER | 75-2616977-002 | 01 | TX | TRICARE | OTHER | 349308201 | 05 | TX | MEDICAID |