Provider Demographics
NPI:1033298393
Name:ALFONSO, MAYRA I (MD)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:I
Last Name:ALFONSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8221 NADMAR AVE
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33434-6306
Mailing Address - Country:US
Mailing Address - Phone:727-748-7860
Mailing Address - Fax:
Practice Address - Street 1:4847 DAVID S MACK DR
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33417-8023
Practice Address - Country:US
Practice Address - Phone:561-687-4958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2025-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME114962208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLGX1387Medicaid
SCQ46726Medicaid
ME114962OtherFL MEDICAL LICENSE
SCQ46726Medicaid