Provider Demographics
NPI:1649538224
Name:ALFONSO, JESUS ERNESTO (PTA)
Entity type:Individual
Prefix:
First Name:JESUS
Middle Name:ERNESTO
Last Name:ALFONSO
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10621 SW 88TH ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176
Mailing Address - Country:US
Mailing Address - Phone:786-287-5041
Mailing Address - Fax:305-270-0206
Practice Address - Street 1:10621 SW 88TH ST
Practice Address - Street 2:SUITE 209
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-8708
Practice Address - Country:US
Practice Address - Phone:786-287-5041
Practice Address - Fax:305-270-0206
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA23100225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant