Provider Demographics
NPI:1154307106
Name:TRONCOSO, ALEXIS BOLIVAR (MD)
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:BOLIVAR
Last Name:TRONCOSO
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 1:2 EASTERN DR
Mailing Address - Street 2:
Mailing Address - City:KENDALL PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:08824-1322
Mailing Address - Country:US
Mailing Address - Phone:732-297-2411
Mailing Address - Fax:732-545-0038
Practice Address - Street 1:137 LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:NEW BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08901-2420
Practice Address - Country:US
Practice Address - Phone:732-545-0051
Practice Address - Fax:732-545-0038
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MAO35210207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0316186EMedicaid
NJ207Q00000XOtherTAXONOMY
NJTR461707Medicare ID - Type Unspecified
NJC56295Medicare UPIN