Provider Demographics
NPI:1285714469
Name:MIDURA, ALAN T (MD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:T
Last Name:MIDURA
Suffix:
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 1:209 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-5429
Mailing Address - Country:US
Mailing Address - Phone:607-257-5263
Mailing Address - Fax:607-216-0902
Practice Address - Street 1:209 W STATE ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-5429
Practice Address - Country:US
Practice Address - Phone:607-257-5263
Practice Address - Fax:607-216-0902
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY162420207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00898908Medicaid
NYE45164Medicare UPIN
NY00898908Medicaid