1487631396 NPI number — DR. WINSTON N HOLLISTER MD

Table of content: DR. WINSTON N HOLLISTER MD (NPI 1487631396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487631396 NPI number — DR. WINSTON N HOLLISTER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOLLISTER
Provider First Name:
WINSTON
Provider Middle Name:
N
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487631396
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14275 MIDWAY RD
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
ADDISON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75001-3614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-932-8029
Provider Business Mailing Address Fax Number:
610-271-4245

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 DELAFIELD ST
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
WAUKESHA
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53188-3417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-542-9173
Provider Business Practice Location Address Fax Number:
262-542-4312
Provider Enumeration Date:
12/30/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  18665 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207ZP0102X , with the licence number: 18665 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 30541000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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