Provider Demographics
NPI:1104811488
Name:HOLM, MARILYN KAY (OD)
Entity type:Individual
Prefix:DR
First Name:MARILYN
Middle Name:KAY
Last Name:HOLM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 W FRONT ST STE A
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-2609
Mailing Address - Country:US
Mailing Address - Phone:360-452-7891
Mailing Address - Fax:
Practice Address - Street 1:240 W FRONT ST STE A
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-2609
Practice Address - Country:US
Practice Address - Phone:360-452-7891
Practice Address - Fax:360-452-8087
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK334152W00000X
KS1550152W00000X
CO3846152W00000X
WAOD61684652152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2062367OtherFIRST HEALTH
KS100346290DMedicaid
KS13089OtherPHS
KS651065OtherBCBS
KS398580OtherFIRSTGUARD
MH0458706OtherDEA
2062367OtherFIRST HEALTH
KS651068Medicare ID - Type Unspecified
KS651065OtherBCBS