Provider Demographics
NPI:1821695156
Name:ALONSO, SERGIO GABRIEL
Entity Type:Individual
Prefix:DR
First Name:SERGIO
Middle Name:GABRIEL
Last Name:ALONSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:527 N STATE OF FRANKLIN RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-8210
Mailing Address - Country:US
Mailing Address - Phone:423-975-0597
Mailing Address - Fax:423-975-6304
Practice Address - Street 1:527 N STATE OF FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-8210
Practice Address - Country:US
Practice Address - Phone:423-975-0597
Practice Address - Fax:423-975-6304
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN42136183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist