Basic Information
Provider Information | |||||||||
NPI: | 1710931688 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALONSO | ||||||||
FirstName: | JORGE | ||||||||
MiddleName: | E | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 40480 | ||||||||
Address2: |   | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366400480 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2514705842 | ||||||||
FaxNumber: | 2514705809 | ||||||||
Practice Location | |||||||||
Address1: | 3421 MEDICAL PARK DR | ||||||||
Address2: | MED PARK II | ||||||||
City: | MOBILE | ||||||||
State: | AL | ||||||||
PostalCode: | 366933330 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2516658200 | ||||||||
FaxNumber: | 2516658210 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/22/2006 | ||||||||
LastUpdateDate: | 10/27/2008 | ||||||||
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 | 207X00000X | L1748 | AL | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 010033CD32883 | 01 | AL | SECTION 1011 | OTHER | 051529634 | 01 | AL | BLUE CROSS | OTHER | D32883 | 01 | AL | VIVA | OTHER | 000080124 | 01 | AL | BLUE CROSS | OTHER | 009932414 | 05 | AL |   | MEDICAID | 51592978 | 01 | AL | BCBS - 3421 MED PK DR | OTHER | 000080124 | 05 | AL |   | MEDICAID |