Provider Demographics
NPI:1942383914
Name:HOLLOMAN, WALTER G JR (MD)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:G
Last Name:HOLLOMAN
Suffix:JR
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 1:55 WESTPORT PLZ
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3109
Mailing Address - Country:US
Mailing Address - Phone:314-548-4772
Mailing Address - Fax:314-548-4748
Practice Address - Street 1:3015 N NEW BALLAS RD
Practice Address - Street 2:
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131
Practice Address - Country:US
Practice Address - Phone:314-996-5180
Practice Address - Fax:314-821-2180
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR65962085R0202X
IL0360616402085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
135370OtherH LINK
A12402OtherGATE WAY
002013128OtherCARE
1600226OtherPH PLAN
6167OtherMCARE USA
2781OtherGHP
27600OtherBLUE CHOICE
300066998OtherRR CARE
017012444OtherMO CARE
04802710571OtherIL CAID
201047818OtherMO CAID
201047818OtherMC MCAID
431725842MIDOtherMERCY
002013128OtherMO CARE
017012444OtherCARE
398023OtherHLT PART
0090000352OtherIL BLUE
1390OtherMO BLUE
135370OtherH LINK
431725842MIDOtherMERCY