Provider Demographics
NPI:1972698108
Name:ALFONSO, ISRAEL (MD)
Entity Type:Individual
Prefix:
First Name:ISRAEL
Middle Name:
Last Name:ALFONSO
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 1:3200 SW 60 CT
Mailing Address - Street 2:SUITE #302
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155-4071
Mailing Address - Country:US
Mailing Address - Phone:305-662-8330
Mailing Address - Fax:305-663-2813
Practice Address - Street 1:3200 SW 60 CT
Practice Address - Street 2:SUITE #302
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155
Practice Address - Country:US
Practice Address - Phone:305-662-8330
Practice Address - Fax:305-669-6496
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00331642084N0402X
FLME331642084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL044365400Medicaid
D63690Medicare UPIN
FL044365400Medicaid