Provider Demographics
NPI:1750431953
Name:HERNANDEZ - ORTIZ, ALFONSO ANTONIO (MD)
Entity type:Individual
Prefix:DR
First Name:ALFONSO
Middle Name:ANTONIO
Last Name:HERNANDEZ - ORTIZ
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 1:2225 PONCE BYP STE 709
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00717-1379
Mailing Address - Country:US
Mailing Address - Phone:787-259-1265
Mailing Address - Fax:787-259-1266
Practice Address - Street 1:2225 PONCE BYP STE 709
Practice Address - Street 2:
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00717-1379
Practice Address - Country:US
Practice Address - Phone:787-259-1265
Practice Address - Fax:787-259-1266
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR8745174400000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PRE58684Medicare UPIN
PR0082160Medicare ID - Type Unspecified