Provider Demographics
NPI:1053678052
Name:SAN DIEGO, ALEXANDER FERNANDO JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:FERNANDO
Last Name:SAN DIEGO
Suffix:JR
Gender:M
Credentials:DPM
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Mailing Address - Street 1:2404 N COURTENAY PKWY
Mailing Address - Street 2:
Mailing Address - City:MERRITT ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32953-4191
Mailing Address - Country:US
Mailing Address - Phone:321-452-1327
Mailing Address - Fax:321-454-9208
Practice Address - Street 1:2404 N COURTENAY PKWY
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32953-4191
Practice Address - Country:US
Practice Address - Phone:321-452-1327
Practice Address - Fax:321-454-9208
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLPO3686213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1053678052OtherNPI
13574563OtherCAQH