Provider Demographics
NPI:1598760670
Name:ALFONSO, ANTONIO E (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTONIO
Middle Name:E
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 1:339 HICKS ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5509
Mailing Address - Country:US
Mailing Address - Phone:718-875-3244
Mailing Address - Fax:718-780-1037
Practice Address - Street 1:100 AMITY ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-6005
Practice Address - Country:US
Practice Address - Phone:718-875-3244
Practice Address - Fax:718-780-1037
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-16
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY117277208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4466282OtherAETNA
NY0077128OtherGHI
NY644021OtherEMPIRE BC & BS
NY00217047Medicaid
NYKS 359OtherOXFORD
NY644021Medicare ID - Type Unspecified
NYB17470Medicare UPIN