Provider Demographics
NPI:1144264235
Name:HOLT, CLIFFORD L (OD)
Entity type:Individual
Prefix:
First Name:CLIFFORD
Middle Name:L
Last Name:HOLT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6435 NIEMAN RD
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66203-3325
Mailing Address - Country:US
Mailing Address - Phone:913-631-6959
Mailing Address - Fax:
Practice Address - Street 1:6435 NIEMAN RD
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66203-3325
Practice Address - Country:US
Practice Address - Phone:913-631-6959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-16
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1261-3152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS13529011OtherBLUE CROSS BLUE SHIELD
KS100218370AMedicaid
UO8550Medicare UPIN
KSM970816Medicare ID - Type Unspecified