Provider Demographics
NPI:1730203118
Name:HOLCOMB, JOHN REYNOLDS (OD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:REYNOLDS
Last Name:HOLCOMB
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 1:25910 IRIS AVE
Mailing Address - Street 2:SUITE A2
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-1657
Mailing Address - Country:US
Mailing Address - Phone:951-243-3337
Mailing Address - Fax:951-243-6868
Practice Address - Street 1:25910 IRIS AVE
Practice Address - Street 2:SUITE A2
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92551-1657
Practice Address - Country:US
Practice Address - Phone:951-243-3337
Practice Address - Fax:951-243-6868
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11653T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAV00386Medicare UPIN
CASD0116530Medicare ID - Type Unspecified