Basic Information
| Provider Information | |||||||||
| NPI: | 1528009990 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | IEROKOMOS | ||||||||
| FirstName: | ALEXANDER | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1020 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952013120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094686000 | ||||||||
| FaxNumber: | 2094687042 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | FRENCH CAMP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952319693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094686000 | ||||||||
| FaxNumber: | 2094687042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2006 | ||||||||
| LastUpdateDate: | 05/03/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207YS0012X | MD00022010 | WA | N | Allopathic & Osteopathic Physicians | Otolaryngology | Sleep Medicine | 207YX0905X | MD00022010 | WA | N | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery | 207YX0007X | MD00022010 | WA | N | Allopathic & Osteopathic Physicians | Otolaryngology | Plastic Surgery within the Head & Neck | 207YX0602X | MD00022010 | WA | N | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngic Allergy | 204E00000X | MD00022010 | WA | N | Allopathic & Osteopathic Physicians | Oral & Maxillofacial Surgery | 207Y00000X | G41004 | CA | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 1379502 | 05 | WA | MEDICAID | 0060170 | 01 | WA | LABOR AND INDUSTRIES | OTHER | 1528009990 | 05 | CA | MEDICAID |