Basic Information
| Provider Information | |||||||||
| NPI: | 1861402778 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLT | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 497 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720060497 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703472534 | ||||||||
| FaxNumber: | 8703471235 | ||||||||
| Practice Location | |||||||||
| Address1: | 1503 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DES ARC | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720403299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702564178 | ||||||||
| FaxNumber: | 8702564085 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | E13027 | AR | N | Allopathic & Osteopathic Physicians | Family Medicine | 207RC0000X | MD.12690R | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | E-13027 | AR | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | MD.12690R | LA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207R00000X | E-13027 | AR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 204499001 | 05 | AR | MEDICAID | P00755804 | 01 | LA | RAILROAD MEDICARE | OTHER |