Basic Information
| Provider Information | |||||||||
| NPI: | 1679912208 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLMES | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18444 N 25TH AVE | ||||||||
| Address2: | 310 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669742673 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18444 N 25TH AVE | ||||||||
| Address2: | 210 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850231261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669742673 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2013 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
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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 | VA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 213ES0103X | 0841 | AZ | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.