Provider Demographics
NPI:1427055532
Name:MIRELES, ALFONSO (MD)
Entity type:Individual
Prefix:
First Name:ALFONSO
Middle Name:
Last Name:MIRELES
Suffix:
Gender:M
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:PO BOX 191
Mailing Address - Street 2:PROVIDER ENROLLMENT DEPARTMENT
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-4488
Mailing Address - Fax:302-651-4945
Practice Address - Street 1:521 WEST STATE ROAD 434, SUITE 101 PEDIATRIC
Practice Address - Street 2:& ADOLESCENT MED OF SEMINOLE, IN ASSOC WITH NEMOURS
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4952
Practice Address - Country:US
Practice Address - Phone:407-830-5437
Practice Address - Fax:407-830-4907
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME54968208000000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL047733800Medicaid
FL'047733800Medicaid
D88992Medicare UPIN