Provider Demographics
NPI:1508934357
Name:ALFONSO, AGUSTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:AGUSTIN
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 1:7000 SW 97TH AVE
Mailing Address - Street 2:#208
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33173
Mailing Address - Country:US
Mailing Address - Phone:305-667-7220
Mailing Address - Fax:305-667-6607
Practice Address - Street 1:7000 SW 97TH AVE
Practice Address - Street 2:#208
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33173
Practice Address - Country:US
Practice Address - Phone:305-667-7220
Practice Address - Fax:305-667-6607
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83617207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262975500Medicaid
FL262975500Medicaid