Provider Demographics
NPI:1003910654
Name:ALFONSO, JORGE (MD)
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:ALFONSO
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:PO BOX 25487
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34277-2487
Mailing Address - Country:US
Mailing Address - Phone:941-202-5342
Mailing Address - Fax:877-807-0253
Practice Address - Street 1:10900 SE 174TH PLACE RD
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-8984
Practice Address - Country:US
Practice Address - Phone:352-820-3401
Practice Address - Fax:352-820-3402
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83696207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL06740WOtherMEDICARE NUMBER
H55166Medicare UPIN