Provider Demographics
NPI:1881100121
Name:ALFONSO, OCTAVIO MIGUEL (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:OCTAVIO
Middle Name:MIGUEL
Last Name:ALFONSO
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:7950 NW 53RD ST STE 337
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33166-4791
Mailing Address - Country:US
Mailing Address - Phone:305-901-4344
Mailing Address - Fax:866-480-9591
Practice Address - Street 1:1951 NW 7TH AVE STE 300
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1112
Practice Address - Country:US
Practice Address - Phone:305-902-6347
Practice Address - Fax:727-306-8033
Is Sole Proprietor?:No
Enumeration Date:2017-12-22
Last Update Date:2021-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9243092363LF0000X
FL9243092363LP0808X
FLAPRN9243092363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109440600Medicaid