Provider Demographics
NPI:1184199739
Name:LEON ALFONSO, PEDRO E
Entity Type:Individual
Prefix:
First Name:PEDRO
Middle Name:E
Last Name:LEON ALFONSO
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 1:8425 NW 169TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33016-6160
Mailing Address - Country:US
Mailing Address - Phone:786-714-9842
Mailing Address - Fax:
Practice Address - Street 1:1905 NW 82ND AVE
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33126-1011
Practice Address - Country:US
Practice Address - Phone:786-420-5924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCBHCM100425171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator