Provider Demographics
NPI:1063513638
Name:ALEXANDER P GURROLA MD PC
Entity type:Organization
Organization Name:ALEXANDER P GURROLA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:P
Authorized Official - Last Name:GURROLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-226-6500
Mailing Address - Street 1:PO BOX 1986
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1986
Mailing Address - Country:US
Mailing Address - Phone:580-226-6500
Mailing Address - Fax:580-226-6524
Practice Address - Street 1:812 12TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-5708
Practice Address - Country:US
Practice Address - Phone:580-226-6500
Practice Address - Fax:580-226-6524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2015-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16537207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100214670AMedicaid
E08020Medicare UPIN
OK559924750Medicare PIN