Provider Demographics
NPI:1205611845
Name:ALFARO CORNEJO, JUAN (CSFA)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:ALFARO CORNEJO
Suffix:
Gender:M
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 THUNDERBIRD DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-3509
Mailing Address - Country:US
Mailing Address - Phone:903-286-7671
Mailing Address - Fax:
Practice Address - Street 1:828 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2042
Practice Address - Country:US
Practice Address - Phone:903-646-5350
Practice Address - Fax:888-501-1092
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant