Provider Demographics
NPI:1013586783
Name:HOFSTRA, ALEXANDER
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:
Last Name:HOFSTRA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12389 ANTONIO CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-3295
Mailing Address - Country:US
Mailing Address - Phone:407-373-4110
Mailing Address - Fax:
Practice Address - Street 1:2220 E IRLO BRONSON MEMORIAL HWY STE 8
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-4411
Practice Address - Country:US
Practice Address - Phone:407-483-7497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB668996106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL110388900Medicaid