Provider Demographics
NPI:1992864359
Name:ALONSO, LUIS (MD)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:
Last Name:ALONSO
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 1:1062 BARNES ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492
Mailing Address - Country:US
Mailing Address - Phone:203-294-6328
Mailing Address - Fax:203-294-6346
Practice Address - Street 1:1062 BARNES ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492
Practice Address - Country:US
Practice Address - Phone:203-294-6328
Practice Address - Fax:203-294-6346
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016387208000000X, 2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0Q2160OtherHEALTHNET
P387376OtherOXFORD
749832OtherCONNECTICARE
83192OtherAETNA
CT001163872Medicaid
83192OtherAETNA
F12715Medicare UPIN