Provider Demographics
NPI:1235309915
Name:HOLTSCLAW, JOHN D (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:HOLTSCLAW
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 1:508 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08104
Mailing Address - Country:US
Mailing Address - Phone:856-338-1811
Mailing Address - Fax:856-541-0719
Practice Address - Street 1:508 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08104
Practice Address - Country:US
Practice Address - Phone:856-338-1811
Practice Address - Fax:856-541-0719
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-10
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
25MA07504100261QM2800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadone
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8635200Medicaid
NJ8648204Medicaid
NJ8635200Medicaid