Basic Information
| Provider Information | |||||||||
| NPI: | 1326340365 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MARTHA N ALFONSO O.D.P.A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11476 NW 81ST TER | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331781487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3054638032 | ||||||||
| FaxNumber: | 7863604907 | ||||||||
| Practice Location | |||||||||
| Address1: | 366 E 4TH AVE | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330104998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058889910 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2010 | ||||||||
| LastUpdateDate: | 11/24/2010 | ||||||||
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| AuthorizedOfficialLastName: | ALFONSO | ||||||||
| AuthorizedOfficialFirstName: | MARTHA | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | OPTOMETRIST | ||||||||
| AuthorizedOfficialTelephone: | 3054638032 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3313 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 620507100 | 05 | FL | MEDICAID |