Provider Demographics
NPI:1891861241
Name:ALFARAZ, CARLOS RODOLFO (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:RODOLFO
Last Name:ALFARAZ
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 1:1310 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN DELLS
Mailing Address - State:WI
Mailing Address - Zip Code:53965-1358
Mailing Address - Country:US
Mailing Address - Phone:608-253-1171
Mailing Address - Fax:608-253-8012
Practice Address - Street 1:1310 BROADWAY
Practice Address - Street 2:
Practice Address - City:WISCONSIN DELLS
Practice Address - State:WI
Practice Address - Zip Code:53965-1358
Practice Address - Country:US
Practice Address - Phone:608-253-1171
Practice Address - Fax:608-253-8012
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2012-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060737207Q00000X
WI56134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP01038284OtherRAILROAD MEDICARE
WI100016791Medicaid
WI61204OtherDEAN HEALTH INSURANCE
WI2058269OtherPHYSICIAN'S PLUS
WI132150136Medicare PIN
WI2058269OtherPHYSICIAN'S PLUS
WIP01038284OtherRAILROAD MEDICARE
WI100016791Medicaid