Provider Demographics
NPI:1669415808
Name:PUERTO, ALFONSO (MD)
Entity type:Individual
Prefix:DR
First Name:ALFONSO
Middle Name:
Last Name:PUERTO
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:PO BOX 436809
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40253-6809
Mailing Address - Country:US
Mailing Address - Phone:502-899-1246
Mailing Address - Fax:502-899-1292
Practice Address - Street 1:10806 WARD AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40223-2659
Practice Address - Country:US
Practice Address - Phone:502-899-1246
Practice Address - Fax:502-899-1292
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYLL339208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP100031756OtherMEDICARE PAY TO PROVIDER NUMBER
KY012087671OtherRAILROAD MEDICARE
KY1059063OtherPASSPORT HEALTHPLAN
KY64993397Medicaid
KYP400031727OtherMEDICARE PERFORMING PROVIDER NUMBER
KYP400031727OtherMEDICARE PERFORMING PROVIDER NUMBER