Provider Demographics
NPI:1821097130
Name:CERVANTES, ALFREDO (MD)
Entity Type:Individual
Prefix:
First Name:ALFREDO
Middle Name:
Last Name:CERVANTES
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 1:71 SOUTH FLANNAGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266
Mailing Address - Country:US
Mailing Address - Phone:276-883-8042
Mailing Address - Fax:276-883-8044
Practice Address - Street 1:71 SOUTH FLANNAGAN AVE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266
Practice Address - Country:US
Practice Address - Phone:276-883-8042
Practice Address - Fax:276-883-8044
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010569732084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1821097130Medicaid
VA017066B12Medicare PIN
VA1821097130Medicaid