Provider Demographics
NPI:1164992632
Name:FORCELLEDO, ALEJANDRO J
Entity Type:Individual
Prefix:
First Name:ALEJANDRO
Middle Name:J
Last Name:FORCELLEDO
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 1:12633 SW 54TH ST
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-5491
Mailing Address - Country:US
Mailing Address - Phone:786-316-5874
Mailing Address - Fax:
Practice Address - Street 1:12633 SW 54TH ST
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-5491
Practice Address - Country:US
Practice Address - Phone:786-316-5874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9281187363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9281187OtherOTHER