Provider Demographics
NPI:1356339733
Name:ALFONSO, FERDINAND A (MD)
Entity type:Individual
Prefix:MR
First Name:FERDINAND
Middle Name:A
Last Name:ALFONSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:MR
Other - First Name:FERDINAND
Other - Middle Name:A
Other - Last Name:ALFONSO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:931 BUENA VISTA ST
Mailing Address - Street 2:SUITE 503
Mailing Address - City:DUARTE
Mailing Address - State:CA
Mailing Address - Zip Code:91010-1712
Mailing Address - Country:US
Mailing Address - Phone:626-357-8003
Mailing Address - Fax:626-357-8402
Practice Address - Street 1:931 BUENA VISTA ST
Practice Address - Street 2:SUITE 503
Practice Address - City:DUARTE
Practice Address - State:CA
Practice Address - Zip Code:91010-1712
Practice Address - Country:US
Practice Address - Phone:626-357-8003
Practice Address - Fax:626-357-8402
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA401142084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A40114Medicaid
CAA40114Medicare ID - Type Unspecified
CA00A40114Medicaid