Healthcare Provider Details

I. General information

NPI: 1598968380
Provider Name (Legal Business Name): JEREMIAH ANDREW ALT M.D., PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 10/16/2021
Certification Date: 10/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 SW BOND AVE # CH5E
PORTLAND OR
97239-3098
US

IV. Provider business mailing address

3303 SW BOND AVE # CH5E
PORTLAND OR
97239-3098
US

V. Phone/Fax

Practice location:
  • Phone: 503-494-5678
  • Fax: 503-494-4631
Mailing address:
  • Phone: 503-494-5678
  • Fax: 503-494-4631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberMD156611
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberTRN11153
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: