Provider Demographics
NPI:1609899475
Name:CARDENAS, ALFONSO (MD)
Entity Type:Individual
Prefix:
First Name:ALFONSO
Middle Name:
Last Name:CARDENAS
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:PO BOX 24921
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76124-1921
Mailing Address - Country:US
Mailing Address - Phone:817-451-4208
Mailing Address - Fax:
Practice Address - Street 1:500 N HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SHERMAN
Practice Address - State:TX
Practice Address - Zip Code:75092-7354
Practice Address - Country:US
Practice Address - Phone:903-870-4609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ3759207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136862313Medicaid
TX86936XOtherBLUECROSS BLUESHIELD
TX8P0430OtherBLUE CROSS BLUE SHIELD
TX136862316Medicaid
TX136862316Medicaid
E72062Medicare UPIN
TX8C6940Medicare PIN
TX8P0430OtherBLUE CROSS BLUE SHIELD
TX136862313Medicaid