Provider Demographics
NPI:1033298393
Name:ALFONSO, MAYRA I (MD)
Entity Type:Individual
Prefix:
First Name:MAYRA
Middle Name:I
Last Name:ALFONSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7045 EVERGREEN WOODS TRL
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34608-1306
Mailing Address - Country:US
Mailing Address - Phone:352-596-8371
Mailing Address - Fax:
Practice Address - Street 1:1902 59TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-4602
Practice Address - Country:US
Practice Address - Phone:941-761-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2018-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114962208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME114962OtherFL MEDICAL LICENSE
SCQ46726Medicaid
ME114962OtherFL MEDICAL LICENSE
SCQ46726Medicaid