Provider Demographics
NPI:1902898729
Name:HOLLOWAY, SANDRA K (MD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:K
Last Name:HOLLOWAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1247 NE MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-3786
Mailing Address - Country:US
Mailing Address - Phone:541-322-5753
Mailing Address - Fax:541-278-8377
Practice Address - Street 1:1501 NE MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-6051
Practice Address - Country:US
Practice Address - Phone:541-382-2811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101043770207RG0100X
ORMD26430207RG0100X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR00422280OtherMEDICARE RAILROAD
OR271028Medicaid
ORR135664Medicare PIN
OR00422280OtherMEDICARE RAILROAD
VAD42809Medicare UPIN
VAD42809Medicare UPIN
VA110004957Medicare ID - Type Unspecified
ORR135664Medicare PIN
VA100000064Medicare ID - Type Unspecified