Provider Demographics
NPI:1134190721
Name:ALONZO, CLIVE LIONEL (MD)
Entity type:Individual
Prefix:DR
First Name:CLIVE
Middle Name:LIONEL
Last Name:ALONZO
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 1:11831 S BISHOP ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-5013
Mailing Address - Country:US
Mailing Address - Phone:773-368-6395
Mailing Address - Fax:
Practice Address - Street 1:600 GRANT ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-6001
Practice Address - Country:US
Practice Address - Phone:773-368-6395
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112177208M00000X, 207R00000X
IN01060964A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200534280Medicaid
INP00664351OtherMEDICARE RAILROAD
IN000000577319OtherANTHEM
INP00632889OtherMEDICARE RAILROAD
IN256480002Medicare PIN
IN200534280Medicaid
IN000000577319OtherANTHEM
INP00632889OtherMEDICARE RAILROAD