Provider Demographics
NPI:1225085590
Name:URDANETA, ALFONSO E (MD)
Entity Type:Individual
Prefix:DR
First Name:ALFONSO
Middle Name:E
Last Name:URDANETA
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 1:3416 HOTZE ROAD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-6616
Mailing Address - Country:US
Mailing Address - Phone:618-548-1185
Mailing Address - Fax:
Practice Address - Street 1:705 SOUTH GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:IL
Practice Address - Zip Code:62263-1534
Practice Address - Country:US
Practice Address - Phone:618-327-2225
Practice Address - Fax:618-327-2229
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036047128208600000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CH2162Medicare UPIN
ILL79586Medicare ID - Type Unspecified