Basic Information
| Provider Information | |||||||||
| NPI: | 1780678409 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLMES | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 77 GOODELL STREET | ||||||||
| Address2: | STE. 240 | ||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142031243 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166459694 | ||||||||
| FaxNumber: | 7168456699 | ||||||||
| Practice Location | |||||||||
| Address1: | 462 GRIDER STREET | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142153021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168318612 | ||||||||
| FaxNumber: | 7168985719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2005 | ||||||||
| LastUpdateDate: | 07/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1971321 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0401X | 197132-1 | NY | N | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207Q00000X | 197132-1 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01625516 | 05 | NY | MEDICAID |