Provider Demographics
NPI:1750484556
Name:ALFONSO G LLANTO MD PC
Entity Type:Organization
Organization Name:ALFONSO G LLANTO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JOSEPHINE
Authorized Official - Middle Name:A
Authorized Official - Last Name:LLANTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-463-5711
Mailing Address - Street 1:POB 127
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:MI
Mailing Address - Zip Code:49098
Mailing Address - Country:US
Mailing Address - Phone:269-463-5711
Mailing Address - Fax:269-463-2885
Practice Address - Street 1:3973 M 140
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:MI
Practice Address - Zip Code:49098
Practice Address - Country:US
Practice Address - Phone:269-463-5711
Practice Address - Fax:269-463-2885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAL038737208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1101156072OtherBCBS
MI2093395Medicaid
P00061231OtherRAILROAD MEDICARE
0115607Medicare ID - Type Unspecified
MI2093395Medicaid