Provider Demographics
NPI:1598968380
Name:ALT, JEREMIAH ANDREW (MD, PHD)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:ANDREW
Last Name:ALT
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3303 SW BOND AVE # CH5E
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3098
Mailing Address - Country:US
Mailing Address - Phone:503-494-5678
Mailing Address - Fax:503-494-4631
Practice Address - Street 1:3303 SW BOND AVE # CH5E
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3098
Practice Address - Country:US
Practice Address - Phone:503-494-5678
Practice Address - Fax:503-494-4631
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2021-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN11153208600000X
ORMD156611207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No208600000XAllopathic & Osteopathic PhysiciansSurgery