Provider Demographics
NPI:1952049967
Name:SMALL, ALFONSO W
Entity Type:Individual
Prefix:
First Name:ALFONSO
Middle Name:W
Last Name:SMALL
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 1:215 HARRY S TRUMAN DR APT 22
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-2045
Mailing Address - Country:US
Mailing Address - Phone:202-657-1108
Mailing Address - Fax:
Practice Address - Street 1:4202 13TH ST NW APT 212
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20011-5644
Practice Address - Country:US
Practice Address - Phone:202-657-1108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-20
Last Update Date:2022-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health