Provider Demographics
NPI:1902335698
Name:HOLLER, BENJAMIN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:HOLLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12142 S YUKON AVENUE
Mailing Address - Street 2:
Mailing Address - City:GLENPOOL
Mailing Address - State:OK
Mailing Address - Zip Code:74033-6621
Mailing Address - Country:US
Mailing Address - Phone:918-935-3636
Mailing Address - Fax:918-777-9019
Practice Address - Street 1:12142 S YUKON AVENUE
Practice Address - Street 2:
Practice Address - City:GLENPOOL
Practice Address - State:OK
Practice Address - Zip Code:74033-6621
Practice Address - Country:US
Practice Address - Phone:918-935-3636
Practice Address - Fax:918-777-9019
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY52911207P00000X
KYR4433207P00000X
OK38874207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine