Provider Demographics
NPI:1093930190
Name:ALFONSO, DAVID R (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:R
Last Name:ALFONSO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:220 LYON ST NW
Mailing Address - Street 2:SUITE 700
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2208
Mailing Address - Country:US
Mailing Address - Phone:616-451-4500
Mailing Address - Fax:616-451-9077
Practice Address - Street 1:220 LYON ST NW
Practice Address - Street 2:SUITE 700
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2208
Practice Address - Country:US
Practice Address - Phone:616-451-4500
Practice Address - Fax:616-451-9077
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2018-11-20
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301080202208200000X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY88B32ET041Medicare PIN