Basic Information
Provider Information | |||||||||
NPI: | 1164783858 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STERN | ||||||||
FirstName: | ALEXANDRA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WIGGINS | ||||||||
OtherFirstName: | ALEXANDRA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 86 W UNDERWOOD ST STE 202 | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328061110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4076496876 | ||||||||
FaxNumber: | 4078720544 | ||||||||
Practice Location | |||||||||
Address1: | 86 W UNDERWOOD ST STE 202 | ||||||||
Address2: |   | ||||||||
City: | ORLANDO | ||||||||
State: | FL | ||||||||
PostalCode: | 328061110 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4076496876 | ||||||||
FaxNumber: | 4078720544 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/30/2012 | ||||||||
LastUpdateDate: | 08/26/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | TRN17556 | FL | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 208000000X | ME122141 | FL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 015337200 | 05 | FL |   | MEDICAID |