Provider Demographics
NPI:1255363420
Name:HOLLAND, KRISTY L (MD)
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:L
Last Name:HOLLAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:L
Other - Last Name:WAELTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 8882
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-0882
Mailing Address - Country:US
Mailing Address - Phone:817-451-4208
Mailing Address - Fax:
Practice Address - Street 1:211 S 3RD ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1915
Practice Address - Country:US
Practice Address - Phone:618-234-2120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2015-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-112397207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0008232153OtherBLUECROSS BLUESHIELD
IL06032182OtherBLUE CROSS BLUE SHIELD
IL036112397Medicaid
IL08232204OtherBLUE CROSS BLUE SHIELD
IL08232205OtherBLUE CROSS BLUE SHIELD
IL08232205OtherBLUE CROSS BLUE SHIELD
ILK28768Medicare PIN
IL06032182OtherBLUE CROSS BLUE SHIELD
ILK29008Medicare PIN