Provider Demographics
NPI:1861402778
Name:HOLT, JEFFREY WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:WAYNE
Last Name:HOLT
Suffix:
Gender:M
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:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:870-347-1235
Practice Address - Street 1:1503 MAIN ST
Practice Address - Street 2:
Practice Address - City:DES ARC
Practice Address - State:AR
Practice Address - Zip Code:72040-3299
Practice Address - Country:US
Practice Address - Phone:870-256-4178
Practice Address - Fax:870-256-4085
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE13027207Q00000X
LAMD.12690R207RC0000X, 207RI0011X
ARE-13027207RC0000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR204499001Medicaid
LAP00755804OtherRAILROAD MEDICARE
AR204499001Medicaid
LA1571458Medicaid