1154585115 NPI number — DR. NEZAM IBRAHIM ALTOROK

Table of content: DR. NEZAM IBRAHIM ALTOROK (NPI 1154585115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154585115 NPI number — DR. NEZAM IBRAHIM ALTOROK

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALTOROK
Provider First Name:
NEZAM
Provider Middle Name:
IBRAHIM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TOROK
Provider Other First Name:
NEZAM
Provider Other Middle Name:
IBRAHIM
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1154585115
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3355 GLENDALE AVE
Provider Second Line Business Mailing Address:
3RD FLOOR
Provider Business Mailing Address City Name:
TOLEDO
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
43614-2426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-383-3780
Provider Business Mailing Address Fax Number:
419-383-3269

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3125 TRANSVERSE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TOLEDO
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
43614-8008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
419-383-3780
Provider Business Practice Location Address Fax Number:
419-383-3269
Provider Enumeration Date:
07/17/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  35121127 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RR0500X , with the licence number: 35121127 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 35121127 . This is a "OHIO LICENSE" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".