Basic Information
| Provider Information | |||||||||
| NPI: | 1275677874 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOLTON | ||||||||
| FirstName: | MARA | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 RIDGELY AVE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214011001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102468049 | ||||||||
| FaxNumber: | 4102660895 | ||||||||
| Practice Location | |||||||||
| Address1: | 600 RIDGELY AVE | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214011001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4102468049 | ||||||||
| FaxNumber: | 4102660895 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 06/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | D0066009 | MD | N | Other Service Providers | Specialist | 208800000X | D0066009 | MD | Y | Allopathic & Osteopathic Physicians | Urology |
No ID Information.