Provider Demographics
NPI:1093776080
Name:LIST, JEROME O (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:O
Last Name:LIST
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
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Mailing Address - Street 1:3841 PIPER ST STE S433
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4624
Mailing Address - Country:US
Mailing Address - Phone:907-561-1421
Mailing Address - Fax:907-561-0327
Practice Address - Street 1:12641 OLD GLENN HWY STE 201
Practice Address - Street 2:
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7040
Practice Address - Country:US
Practice Address - Phone:907-561-1421
Practice Address - Fax:907-561-0327
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AK2607207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD1123Medicaid
AKK150876Medicare ID - Type Unspecified
AKMD1123Medicaid