Provider Demographics
NPI:1265574222
Name:ALFONSO, IMELDA C (MD)
Entity type:Individual
Prefix:DR
First Name:IMELDA
Middle Name:C
Last Name:ALFONSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:268 W HOSPITALITY LN
Mailing Address - Street 2:STE. 400
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0001
Mailing Address - Country:US
Mailing Address - Phone:909-382-3087
Mailing Address - Fax:909-382-3106
Practice Address - Street 1:268 W HOSPITALITY LN
Practice Address - Street 2:STE. 400
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-0001
Practice Address - Country:US
Practice Address - Phone:909-382-3087
Practice Address - Fax:909-382-3106
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA397412084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC35248Medicare ID - Type Unspecified