Provider Demographics
NPI:1972809093
Name:ALEXANDER C MBAKWEM MD PA
Entity Type:Organization
Organization Name:ALEXANDER C MBAKWEM MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:C
Authorized Official - Last Name:MBAKWEM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-644-9500
Mailing Address - Street 1:6670 CRESCENT WOODS CIR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-4612
Mailing Address - Country:US
Mailing Address - Phone:863-644-9500
Mailing Address - Fax:863-644-9555
Practice Address - Street 1:5421 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2523
Practice Address - Country:US
Practice Address - Phone:863-644-9500
Practice Address - Fax:863-644-9555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-07
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME92808207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277193400Medicaid
FL277193400Medicaid