Provider Demographics
NPI:1336502277
Name:ALFONSO, JUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:ALFONSO
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 1:5191 FIRST COAST TECH PKWY, 3RD FLOOR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224
Mailing Address - Country:US
Mailing Address - Phone:904-223-3321
Mailing Address - Fax:904-223-2169
Practice Address - Street 1:10475 CENTURION PKWY N STE 201
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-5004
Practice Address - Country:US
Practice Address - Phone:904-223-3321
Practice Address - Fax:904-223-2169
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLME145433207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program