Provider Demographics
NPI:1033378245
Name:ALEXANDER, IAN J (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:J
Last Name:ALEXANDER
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 1:1190 SPRING CREEK PL E1
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-6002
Mailing Address - Country:US
Mailing Address - Phone:505-697-9095
Mailing Address - Fax:
Practice Address - Street 1:34910 INTERSTATE 10 W 3
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-9229
Practice Address - Country:US
Practice Address - Phone:210-202-0250
Practice Address - Fax:505-661-0075
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2015-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT184869207Y00000X
NMMD2009-0464207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM88605761Medicaid
NMNM00194Medicare PIN