Provider Demographics
NPI:1336118017
Name:GORUP, ALEXANDER M (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:M
Last Name:GORUP
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 1:1601 CLINT MOORE RD STE 215
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-5716
Mailing Address - Country:US
Mailing Address - Phone:561-939-0193
Mailing Address - Fax:561-338-6271
Practice Address - Street 1:1601 CLINT MOORE RD STE 105
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-5712
Practice Address - Country:US
Practice Address - Phone:561-391-3333
Practice Address - Fax:561-391-5618
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058318A207Y00000X, 207YS0123X
FLME112703207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200459890Medicaid
IN000000312445OtherANTHEM PROVIDER NUMBER
ING98683Medicare UPIN
IN200459890Medicaid
IN815150NMedicare PIN