Provider Demographics
NPI:1184882136
Name:ILORETA, ALFRED MARC CALO JR (MD)
Entity type:Individual
Prefix:DR
First Name:ALFRED MARC
Middle Name:CALO
Last Name:ILORETA
Suffix:JR
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 1:5 E 98TH ST
Mailing Address - Street 2:8TH FLOOR DEPT OTOLARYNGOLOGY
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-6501
Mailing Address - Country:US
Mailing Address - Phone:212-241-9410
Mailing Address - Fax:
Practice Address - Street 1:5 E 98TH ST
Practice Address - Street 2:8TH FLOOR DEPT OTOLARYNGOLOGY
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6501
Practice Address - Country:US
Practice Address - Phone:212-241-9410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-27
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD448184207Y00000X
NY264716207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0365343Medicaid
PA102839584Medicaid
PA292695Medicare PIN