Basic Information
Provider Information | |||||||||
NPI: | 1013983402 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALFONSO | ||||||||
FirstName: | JORGE | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 297 NORTH ST STE 221 | ||||||||
Address2: |   | ||||||||
City: | HYANNIS | ||||||||
State: | MA | ||||||||
PostalCode: | 026015133 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5088627777 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 495 STATION AVE | ||||||||
Address2: |   | ||||||||
City: | SOUTH YARMOUTH | ||||||||
State: | MA | ||||||||
PostalCode: | 026641218 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5087784777 | ||||||||
FaxNumber: | 5087719555 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/24/2006 | ||||||||
LastUpdateDate: | 06/18/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 223490 | MA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 470367 | 01 |   | TUFTS | OTHER | J28944 | 01 | MA | BCBS | OTHER | AA80003 | 01 |   | PILGRIM | OTHER | 491568 | 01 |   | USFHP | OTHER | 3989691 | 01 |   | AETNA | OTHER |