Provider Demographics
NPI:1093352502
Name:KATIEOSTROMMD
Entity Type:Organization
Organization Name:KATIEOSTROMMD
Other - Org Name:KATIE OSTROM MD, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:ALBA
Authorized Official - Middle Name:I
Authorized Official - Last Name:DIAZ CARMONA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-744-4648
Mailing Address - Street 1:205 W FAIRVIEW
Mailing Address - Street 2:
Mailing Address - City:HOMER
Mailing Address - State:AK
Mailing Address - Zip Code:99603
Mailing Address - Country:US
Mailing Address - Phone:907-435-0555
Mailing Address - Fax:907-435-0559
Practice Address - Street 1:205 W FAIRVIEW
Practice Address - Street 2:
Practice Address - City:HOMER
Practice Address - State:AK
Practice Address - Zip Code:99603
Practice Address - Country:US
Practice Address - Phone:907-435-0555
Practice Address - Fax:907-435-0559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-03
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1007494Medicaid
AK1702227Medicaid