Provider Demographics
NPI:1932168697
Name:ESTRADA, ALFONSO Q (MD)
Entity Type:Individual
Prefix:
First Name:ALFONSO
Middle Name:Q
Last Name:ESTRADA
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 1:221 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4214
Mailing Address - Country:US
Mailing Address - Phone:812-242-3175
Mailing Address - Fax:812-242-3543
Practice Address - Street 1:1429 N 6TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-1037
Practice Address - Country:US
Practice Address - Phone:812-242-3175
Practice Address - Fax:812-242-3543
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-057641174400000X
IN01065735A207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No174400000XOther Service ProvidersSpecialist
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00818711OtherRAILROAD MEDICARE
IL036057641Medicaid
INP00818711OtherRAILROAD MEDICARE
IN265130BMedicare PIN
IN192770B7Medicare PIN
IN859910E3Medicare PIN
IL036057641Medicaid
ILIL3294008Medicare PIN