Provider Demographics
NPI:1528009990
Name:IEROKOMOS, ALEXANDER P (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:P
Last Name:IEROKOMOS
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:PO BOX 1020
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95201-3120
Mailing Address - Country:US
Mailing Address - Phone:209-468-6000
Mailing Address - Fax:209-468-7042
Practice Address - Street 1:500 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9693
Practice Address - Country:US
Practice Address - Phone:209-468-6000
Practice Address - Fax:209-468-7042
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00022010207YS0012X, 207YX0905X, 207YX0007X, 207YX0602X, 204E00000X
CAG41004207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YS0012XAllopathic & Osteopathic PhysiciansOtolaryngologySleep Medicine
No207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
No207YX0007XAllopathic & Osteopathic PhysiciansOtolaryngologyPlastic Surgery within the Head & Neck
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic Allergy
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1379502Medicaid
WA0060170OtherLABOR AND INDUSTRIES
CA1528009990Medicaid
WA0060170OtherLABOR AND INDUSTRIES
WA1379502Medicaid
WA40001914Medicare PIN